- Email: [email protected]
Minocycline-induced orbital rim discoloration
182
Ballard and Brice~ no References
1. Wadhwa N, Venkatesh P, Sampangi R, Garg S. Rhegmatogenous retinal detachments in children in India: clinical characteristics, risk factors, and surgical outcomes. J AAPOS 2008;12:551-4. 2. Ranchod TM, Quiram PA, Hathaway N, Ho LY, Glasgow BJ, Trese MT. Microcornea, posterior megalolenticonus, persistent fetal vasculature, and coloboma: a new syndrome. Ophthalmology 2010; 117:1843-7. 3. Lee JS, Lee JE, Shin YG, Choi HY, Oum BS, Kim HJ. Five cases of microphthalmia with other ocular malformations. Korean J Ophthalmol 2001;15:41-7. 4. Bardakjian TM, Kwok S, Slavotinek AM, Schneider AS. Clinical report of microphthalmia and optic nerve coloboma associated with a de novo microdeletion of chromosome 16p11.2. Am J Med Genet A 2010;152A: 3120-3. 5. Lasky JB, Sandu M, Balashanmugan A. PHACE syndrome: association with persistent fetal vasculature and coloboma-like iris defect. J AAPOS 2004;8:495-8. 6. Barishak YR. Embryology of the eye and its adnexae. Dev Ophthalmol 1992;24:1-142.
Minocycline-induced orbital rim discoloration Tiffany N. S. Ballard, MD,a and C esar A. Brice~ no, MDb, A 20-year-old woman underwent lacrimal gland biopsy for unilateral swelling and was unexpectedly found to have olive-green discoloration of her orbital rim. Postoperative questioning revealed that as a teenager she had been treated for acne with minocycline, a semisynthetic tetracycline antibiotic and a first-line treatment for moderate and severe acne. While hyperpigmentation is a known side effect of minocycline, reports of pigmentation changes of the periorbital bones are relatively rare and could pose a diagnostic dilemma during surgery.
Case Report A 20-year-old woman was referred to the University of Michigan Kellogg Eye Center with a chief complaint of pain, pressure, swelling, and redness of the left eye of about 10 days’ duration. Her surgical history included repeat
Author affiliations: aSection of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan; bDepartment of Ophthalmology, University of Michigan, Ann Arbor, Michigan Submitted October 31, 2014. Revision accepted December 20, 2015. Published online March 15, 2016. Correspondence: Cesar A. Brice~ no, MD, University of Michigan Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI 48105 (email: [email protected]). J AAPOS 2016;20:182-184. Copyright Ó 2016 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.12.002
Volume 20 Number 2 / April 2016 ptosis corrective surgery on the left upper eyelid without complication 2 months prior to presentation. Her initial levator resection for correction of congenital ptosis was performed at the age of 5. The patient’s medical history included asthma and acne, which was treated with minocycline from ages 14 to 16, with a daily dose ranging from 100 mg to 200 mg. (Her minocycline therapy was unknown to treating physicians at the initial examination.) Her current medications included an oral contraceptive and intermittent ibuprofen. Review of systems was negative for fevers, a preceding upper respiratory infection, and xerostomia. The patient’s immunizations were up to date. On initial examination, she was found to have visual acuity of 20/25-1 in the right eye and 20/20 in the left eye, with full visual fields bilaterally. Motility was normal. Intraocular pressure was 13 mm Hg in the right eye and 14 mm Hg in the left eye. Exophthalmometry was 21 mm on the right and 22 mm on the left. Slit-lamp examination was notable for localized 11 injection of the lateral upper forniceal conjunctiva on the left, and the palpebral lobe of the left lacrimal gland was enlarged on palpation and visualization. Magnetic resonance imaging with and without contrast revealed bilateral lacrimal glands to be grossly symmetric in size, signal characteristics, and enhancement pattern. The patient was initially treated with an empiric course of oral steroids but due to adverse psychological side effects the medication was discontinued. The palpebral lobe remained enlarged and tender. After a discussion with the patient and her parents, an incisional biopsy of the left lacrimal gland was performed via anterior orbitotomy through an upper lid crease incision. The dissection was carried through the septum to the arcus marginalis. The periosteum was incised and elevated, revealing discolored, olive-green bone in the region of the enlarged lacrimal gland (Figure 1). A bone biopsy was submitted for histopathology. No discoloration of the periorbital fat or soft tissues was noted. A lacrimal gland biopsy was obtained, and the operation concluded in standard fashion. Pathology of the orbital rim bone, which was decalcified for analysis, revealed fragments of cortical bone with adherent fibrous tissue and a focus of histiocytes and was negative for neoplasia or significant inflammation. The lacrimal gland biopsy displayed patchy chronic nongranulomatous dacryoadenitis with early acinar dropout and fibrosis. Postoperatively, the patient healed well and without complication. The dacryoadenitis resolved with local injections of triamcinolone into the area of the lacrimal gland.
Discussion About 70%-87% of all adolescents are affected by acne vulgaris, a distressing condition involving inflammation of the
Journal of AAPOS
Volume 20 Number 2 / April 2016
FIG 1. Olive green discoloration of the left orbital rim encountered during lacrimal gland biopsy of a 20-year-old woman.
sebaceous glands in the skin.1 A well-documented side effect of minocycline, a first-line treatment for moderate and severe acne and treatment-resistant forms of inflammatory acne, is pigmentation changes, including bluegreen, gray, brown, or black discoloration.2 Generally, pigmentation results from long-term administration at cumulative doses of .100 g, although cutaneous or oral mucosal pigmentation may appear at any dose or duration of therapy.3 The majority of cases concerning bone involve the alveolar bone of the maxilla or mandible, and more than 20% of patients taking minocycline for over 4 years are reported to have discoloration of the bones of the oral cavity.3 In more rare instances, discoloration of the clavicle, femur, tibia, first metatarsal, metacarpals, and spinal vertebrae has been described.4-8 Boulos and colleagues9 encountered 3 instances of discolored orbital bone during orbital tumor excision or fracture repair procedures, and 1 case of a discolored facial skeleton was observed during a coronal approach.10 In our case, olive-green discoloration of bone was noted during an otherwise unremarkable lacrimal gland biopsy for lacrimal gland pain and enlargement of uncertain etiology. The patient had no external findings suggestive of minocycline-related pigmentation changes, including conjunctival or scleral discoloration. The intraoperative appearance of her orbital rim was therefore unexpected and concerning, because the color was similar to that seen in pathologic bone. If such a finding were discovered during an orbital floor repair, for example, there might be concerns regarding the ability of the bone to heal and the soundness of the bone for fixation and plating. In this case, the fact that the bone was in the vicinity of an enlarged lacrimal gland heightened concern for pathology and
Journal of AAPOS
Ballard and Brice~ no
183
necessitated a bone biopsy. While utilizing the osteotome, the bone was noted to be of normal clinical density, and the surrounding tissues were unremarkable. Postoperatively, the patient revealed a history of minocycline therapy and had been previously told that her wisdom tooth was discolored after removal. Minocycline is highly lipid soluble, facilitating penetration into body fluids and tissues. Although it is a yellow crystalline material, its insoluble degradation products are black in color and become trapped in macrophages. These drug-pigment complexes have a predisposition to chelate to iron, ferritin, or hemosiderin.3 Bone pigmentation is irreversible, unlike that of the oral mucosa or skin. Minocycline, like all tetracyclines, autofluorescences under ultraviolet light as a result of its four-ringed molecular structure. Both calcified and decalcified bone containing minocycline will fluoresce. When necessary, ultraviolet fluorescence can be utilized to confirm minocycline as the cause for discoloration during histologic analysis. McCleskey and colleagues for example, who reported a case of blue-green discoloration of the femur and tibia noted during total knee arthroplasty, described diffuse fluorescence with deeply embedded patches of brighter fluorescence consistent with minocycline use. Overall, it is unlikely that there are any potential risks associated with minocycline-induced pigmentation, and no adverse effects of minocycline on the structure or function of bone have been reported.1 In general, however, discontinuation of the drug is recommended once pigmentation related to minocycline therapy has been identified in a patient. If such discoloration is encountered, we recommend obtaining biopsies of the bone and surrounding soft tissues to rule out malignancy and evaluate for fluorescence under ultraviolet light, inquiring about previous minocycline use, and reviewing the patient’s medications. Failure to include minocycline-induced pigmentation in the differential diagnosis may lead to unnecessary testing and confusion with other causes of pigmentation. References 1. Dreno B, Poli F. Epidemiology of acne. Dermatology 2003;206: 7-10. 2. Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007;56:651-63. 3. Eisen D, Hakim MD. Minocycline-induced pigmentation. Incidence, prevention, and management. Drug Saf 1998;18:431-40. 4. Wolfe ID, Reichmaster J. Minocycline hyperpigmentation: Skin, tooth, nail, and bone involvement. Cutis 1984;3:457-8. 5. Kerbleski GJ, Hampton TT, Cornejo A. Black bone disease of the foot: A case study and review of literature demonstrating a correlation of long-term minocycline therapy and bone hyperpigmentation. J Foot Ankle Surg 2013;52:239-41. 6. McCleskey PE, Littleton KH. Minocycline-induced blue-green discoloration of bone. J Bone Joint Surg Am 2004;86-A:146-8. 7. Rumbak MJ, Pitcock JA, Palmieri GM, Robertson JT. Black bones following long-term minocycline treatment. Arch Pathol Lab Med 1991;115:939-41.
184
Motley III et al
Volume 20 Number 2 / April 2016
8. Somayazula R, Rogers GF. Metacarpal darkening associated with minocycline therapy. J Hand Surg Eur Vol 2010;35:760-1. 9. Boulos PR, Knoepp SM, Rubin PAD. Green bone. Arch Ophthalmol 2007;125:380-6. 10. Laure B, Petraud A, Sury F, et al. Black bone disease of the skull and facial bones. Rev Stomatol Chir Maxillofac 2009;110:303-5.
agreement of the OSCAR:Strabismus tool in the assessment of resident performance. OSCAR:Strabismus evaluations of resident surgical strabismus cases were performed by a multinational group of faculty strabismus surgeons. Cronbach a statistical analysis of the completed evaluations revealed high inter-rater agreement, indicating the OSCAR:Strabismus is a reliable tool to facilitate assessment of resident strabismus surgical skills.
Validity of ophthalmology surgical competency assessment rubric for strabismus surgery in resident training
Methods
W. Walker Motley III, MS, MD,a,b, Karl C. Golnik, MD, MEd,b,c Irene Anteby, MD,d Huban Atilla, MD,e Glen A. Gole, MD,f Claudia Murillo, MD,g Scott E. Olitsky, MD,h Rachel F. Pilling, MB, ChB,i Aravind R. Reddy, FRCOphth, FRCSEd,j Pradeep Sharma, MD,k R. Michael Siatkowski, MD,l and Maria B. Yadarola, MDm The Accreditation Council for Graduate Medical Education (ACGME) requires US residency programs to assess ophthalmology residents for competency in 6 core areas. Ophthalmic surgical skills are currently part of the ACGME “Patient Care” competency, although some have advocated for a seventh competency, “Surgical Skills.” The Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery in Resident Training (OSCAR:Strabismus) tool was designed to aid in the assessment of surgical skills using procedure specific behavioral anchors. The present study evaluated inter-rater
Author affiliations: aAbrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH; cCincinnati Eye Institute, Cincinnati, OH; dHadassah Hebrew University, Jerusalem, Israel; eDepartment of Ophthalmology, Ankara University, Faculty of Medicine, Ankara, Turkey; fUniversity of Queensland, Brisbane, Queensland; gStrabismus Department, Instituto de Oftalmologia Fundacion Conde de Valenciana, Mexico; h Children’s Mercy Hospital, Kansas City, Missouri; iDepartment of Ophthalmology, Bradford Royal Infirmary, Bradford, UK; jDepartment of Ophthalmology, Royal Aberdeen Children’s Hospital and University of Aberdeen, Aberdeen, Scotland; kRP Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; lDean McGee Eye Institute, University of Oklahoma, Norman, OK; mDepartment of Pediatric Ophthalmology and Adult Strabismus, Centro de Ojos Romagosa, Cordoba, Argentina Supported in part by a Challenge Grant from Research to Prevent Blindness, Inc to the University of Cincinnati Department of Ophthalmology (James J. Augsburger, MD, Chairman). Research to Prevent Blindness, Inc had no role in the design or conduct of this research. Presented in part as a poster at the Annual Meeting of the American Academy of Ophthalmology, New Orleans, Louisiana, November 16-19, 2013. Submitted September 8, 2015. Revision accepted December 31, 2015. Correspondence: W. Walker Motley, III, MS, MD, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 4008, Cincinnati, OH 45229 (email: [email protected]). J AAPOS 2016;20:184-185. Copyright Ó 2016 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.12.007
Exemption was granted by the Institutional Review Board of Cincinnati Children’s Hospital Medical Center for this study, which conforms with all requirements of the US Health Insurance Portability and Accountability Act of 1996. Five video recordings of horizontal rectus muscle recession surgery performed by 5 different University of Cincinnati ophthalmology residents were distributed to 10 teaching faculty strabismus surgeons, who served as evaluators for this study. The 10 evaluators resided in 9 countries: Argentina, Australia, India, Israel, Mexico, Scotland, Turkey, the United Kingdom, and the United States. All evaluators are experienced strabismus surgeons who routinely train ophthalmology residents at academic institutions. Each evaluator assessed the performance of horizontal rectus recession by each resident using the OSCAR:Strabismus tool (available on the website of the International Council of Ophthalmology, https://www. icoph.org/downloads/ICO-OSCAR-Strabismus.pdf). The surgical steps that would be evaluated by using OSCAR:Strabismus elements 1, 14, and 17 could not be adequately recorded by the videography equipment in the operating room; therefore the evaluators were instructed to not score elements 1, 14, and 17 during their evaluations. Scored evaluations were analyzed for inter-rater agreement using the Cronbach a coefficient, which was computed for the tool as a whole and for the individual elements. A Cronbach a coefficient of $0.7 was considered to demonstrate satisfactory inter-rater agreement; of 0.9, excellent agreement.1 The Pearson correlation coefficient (r) was calculated to evaluate for correlation between OSCAR:Strabismus score and time required for a resident to complete a procedure.
Results Residents’ scores for each OSCAR:Strabismus element are shown in Appendix A (e-only). The mean total score for all 5 residents was 4.0 0.5 (standard deviation). Individual OSCAR:Strabismus element scores ranged from 2.8 to 5.0. Cronbach a coefficients for each OSCAR:Strabismus element as well as the Cronbach a coefficient for the tool as a whole are listed in Table 1. The OSCAR:Strabismus Cronbach a coefficient for the entire assessment tool was above 0.9, indicating excellent inter-rater agreement. When analyzed individually, the OSCAR assessment elements each demonstrated at least satisfactory inter-rater agreement (Cronbach a $ 0.7), with the exception of element 8. The mean time required to complete the surgical procedure was 29 7.1 minutes. The Pearson correlation coefficient for duration of procedure versus OSCAR:Strabismus score was 0.97.
Journal of AAPOS
Ballard and Brice~ no References
1. Wadhwa N, Venkatesh P, Sampangi R, Garg S. Rhegmatogenous retinal detachments in children in India: clinical characteristics, risk factors, and surgical outcomes. J AAPOS 2008;12:551-4. 2. Ranchod TM, Quiram PA, Hathaway N, Ho LY, Glasgow BJ, Trese MT. Microcornea, posterior megalolenticonus, persistent fetal vasculature, and coloboma: a new syndrome. Ophthalmology 2010; 117:1843-7. 3. Lee JS, Lee JE, Shin YG, Choi HY, Oum BS, Kim HJ. Five cases of microphthalmia with other ocular malformations. Korean J Ophthalmol 2001;15:41-7. 4. Bardakjian TM, Kwok S, Slavotinek AM, Schneider AS. Clinical report of microphthalmia and optic nerve coloboma associated with a de novo microdeletion of chromosome 16p11.2. Am J Med Genet A 2010;152A: 3120-3. 5. Lasky JB, Sandu M, Balashanmugan A. PHACE syndrome: association with persistent fetal vasculature and coloboma-like iris defect. J AAPOS 2004;8:495-8. 6. Barishak YR. Embryology of the eye and its adnexae. Dev Ophthalmol 1992;24:1-142.
Minocycline-induced orbital rim discoloration Tiffany N. S. Ballard, MD,a and C esar A. Brice~ no, MDb, A 20-year-old woman underwent lacrimal gland biopsy for unilateral swelling and was unexpectedly found to have olive-green discoloration of her orbital rim. Postoperative questioning revealed that as a teenager she had been treated for acne with minocycline, a semisynthetic tetracycline antibiotic and a first-line treatment for moderate and severe acne. While hyperpigmentation is a known side effect of minocycline, reports of pigmentation changes of the periorbital bones are relatively rare and could pose a diagnostic dilemma during surgery.
Case Report A 20-year-old woman was referred to the University of Michigan Kellogg Eye Center with a chief complaint of pain, pressure, swelling, and redness of the left eye of about 10 days’ duration. Her surgical history included repeat
Author affiliations: aSection of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan; bDepartment of Ophthalmology, University of Michigan, Ann Arbor, Michigan Submitted October 31, 2014. Revision accepted December 20, 2015. Published online March 15, 2016. Correspondence: Cesar A. Brice~ no, MD, University of Michigan Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI 48105 (email: [email protected]). J AAPOS 2016;20:182-184. Copyright Ó 2016 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.12.002
Volume 20 Number 2 / April 2016 ptosis corrective surgery on the left upper eyelid without complication 2 months prior to presentation. Her initial levator resection for correction of congenital ptosis was performed at the age of 5. The patient’s medical history included asthma and acne, which was treated with minocycline from ages 14 to 16, with a daily dose ranging from 100 mg to 200 mg. (Her minocycline therapy was unknown to treating physicians at the initial examination.) Her current medications included an oral contraceptive and intermittent ibuprofen. Review of systems was negative for fevers, a preceding upper respiratory infection, and xerostomia. The patient’s immunizations were up to date. On initial examination, she was found to have visual acuity of 20/25-1 in the right eye and 20/20 in the left eye, with full visual fields bilaterally. Motility was normal. Intraocular pressure was 13 mm Hg in the right eye and 14 mm Hg in the left eye. Exophthalmometry was 21 mm on the right and 22 mm on the left. Slit-lamp examination was notable for localized 11 injection of the lateral upper forniceal conjunctiva on the left, and the palpebral lobe of the left lacrimal gland was enlarged on palpation and visualization. Magnetic resonance imaging with and without contrast revealed bilateral lacrimal glands to be grossly symmetric in size, signal characteristics, and enhancement pattern. The patient was initially treated with an empiric course of oral steroids but due to adverse psychological side effects the medication was discontinued. The palpebral lobe remained enlarged and tender. After a discussion with the patient and her parents, an incisional biopsy of the left lacrimal gland was performed via anterior orbitotomy through an upper lid crease incision. The dissection was carried through the septum to the arcus marginalis. The periosteum was incised and elevated, revealing discolored, olive-green bone in the region of the enlarged lacrimal gland (Figure 1). A bone biopsy was submitted for histopathology. No discoloration of the periorbital fat or soft tissues was noted. A lacrimal gland biopsy was obtained, and the operation concluded in standard fashion. Pathology of the orbital rim bone, which was decalcified for analysis, revealed fragments of cortical bone with adherent fibrous tissue and a focus of histiocytes and was negative for neoplasia or significant inflammation. The lacrimal gland biopsy displayed patchy chronic nongranulomatous dacryoadenitis with early acinar dropout and fibrosis. Postoperatively, the patient healed well and without complication. The dacryoadenitis resolved with local injections of triamcinolone into the area of the lacrimal gland.
Discussion About 70%-87% of all adolescents are affected by acne vulgaris, a distressing condition involving inflammation of the
Journal of AAPOS
Volume 20 Number 2 / April 2016
FIG 1. Olive green discoloration of the left orbital rim encountered during lacrimal gland biopsy of a 20-year-old woman.
sebaceous glands in the skin.1 A well-documented side effect of minocycline, a first-line treatment for moderate and severe acne and treatment-resistant forms of inflammatory acne, is pigmentation changes, including bluegreen, gray, brown, or black discoloration.2 Generally, pigmentation results from long-term administration at cumulative doses of .100 g, although cutaneous or oral mucosal pigmentation may appear at any dose or duration of therapy.3 The majority of cases concerning bone involve the alveolar bone of the maxilla or mandible, and more than 20% of patients taking minocycline for over 4 years are reported to have discoloration of the bones of the oral cavity.3 In more rare instances, discoloration of the clavicle, femur, tibia, first metatarsal, metacarpals, and spinal vertebrae has been described.4-8 Boulos and colleagues9 encountered 3 instances of discolored orbital bone during orbital tumor excision or fracture repair procedures, and 1 case of a discolored facial skeleton was observed during a coronal approach.10 In our case, olive-green discoloration of bone was noted during an otherwise unremarkable lacrimal gland biopsy for lacrimal gland pain and enlargement of uncertain etiology. The patient had no external findings suggestive of minocycline-related pigmentation changes, including conjunctival or scleral discoloration. The intraoperative appearance of her orbital rim was therefore unexpected and concerning, because the color was similar to that seen in pathologic bone. If such a finding were discovered during an orbital floor repair, for example, there might be concerns regarding the ability of the bone to heal and the soundness of the bone for fixation and plating. In this case, the fact that the bone was in the vicinity of an enlarged lacrimal gland heightened concern for pathology and
Journal of AAPOS
Ballard and Brice~ no
183
necessitated a bone biopsy. While utilizing the osteotome, the bone was noted to be of normal clinical density, and the surrounding tissues were unremarkable. Postoperatively, the patient revealed a history of minocycline therapy and had been previously told that her wisdom tooth was discolored after removal. Minocycline is highly lipid soluble, facilitating penetration into body fluids and tissues. Although it is a yellow crystalline material, its insoluble degradation products are black in color and become trapped in macrophages. These drug-pigment complexes have a predisposition to chelate to iron, ferritin, or hemosiderin.3 Bone pigmentation is irreversible, unlike that of the oral mucosa or skin. Minocycline, like all tetracyclines, autofluorescences under ultraviolet light as a result of its four-ringed molecular structure. Both calcified and decalcified bone containing minocycline will fluoresce. When necessary, ultraviolet fluorescence can be utilized to confirm minocycline as the cause for discoloration during histologic analysis. McCleskey and colleagues for example, who reported a case of blue-green discoloration of the femur and tibia noted during total knee arthroplasty, described diffuse fluorescence with deeply embedded patches of brighter fluorescence consistent with minocycline use. Overall, it is unlikely that there are any potential risks associated with minocycline-induced pigmentation, and no adverse effects of minocycline on the structure or function of bone have been reported.1 In general, however, discontinuation of the drug is recommended once pigmentation related to minocycline therapy has been identified in a patient. If such discoloration is encountered, we recommend obtaining biopsies of the bone and surrounding soft tissues to rule out malignancy and evaluate for fluorescence under ultraviolet light, inquiring about previous minocycline use, and reviewing the patient’s medications. Failure to include minocycline-induced pigmentation in the differential diagnosis may lead to unnecessary testing and confusion with other causes of pigmentation. References 1. Dreno B, Poli F. Epidemiology of acne. Dermatology 2003;206: 7-10. 2. Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007;56:651-63. 3. Eisen D, Hakim MD. Minocycline-induced pigmentation. Incidence, prevention, and management. Drug Saf 1998;18:431-40. 4. Wolfe ID, Reichmaster J. Minocycline hyperpigmentation: Skin, tooth, nail, and bone involvement. Cutis 1984;3:457-8. 5. Kerbleski GJ, Hampton TT, Cornejo A. Black bone disease of the foot: A case study and review of literature demonstrating a correlation of long-term minocycline therapy and bone hyperpigmentation. J Foot Ankle Surg 2013;52:239-41. 6. McCleskey PE, Littleton KH. Minocycline-induced blue-green discoloration of bone. J Bone Joint Surg Am 2004;86-A:146-8. 7. Rumbak MJ, Pitcock JA, Palmieri GM, Robertson JT. Black bones following long-term minocycline treatment. Arch Pathol Lab Med 1991;115:939-41.
184
Motley III et al
Volume 20 Number 2 / April 2016
8. Somayazula R, Rogers GF. Metacarpal darkening associated with minocycline therapy. J Hand Surg Eur Vol 2010;35:760-1. 9. Boulos PR, Knoepp SM, Rubin PAD. Green bone. Arch Ophthalmol 2007;125:380-6. 10. Laure B, Petraud A, Sury F, et al. Black bone disease of the skull and facial bones. Rev Stomatol Chir Maxillofac 2009;110:303-5.
agreement of the OSCAR:Strabismus tool in the assessment of resident performance. OSCAR:Strabismus evaluations of resident surgical strabismus cases were performed by a multinational group of faculty strabismus surgeons. Cronbach a statistical analysis of the completed evaluations revealed high inter-rater agreement, indicating the OSCAR:Strabismus is a reliable tool to facilitate assessment of resident strabismus surgical skills.
Validity of ophthalmology surgical competency assessment rubric for strabismus surgery in resident training
Methods
W. Walker Motley III, MS, MD,a,b, Karl C. Golnik, MD, MEd,b,c Irene Anteby, MD,d Huban Atilla, MD,e Glen A. Gole, MD,f Claudia Murillo, MD,g Scott E. Olitsky, MD,h Rachel F. Pilling, MB, ChB,i Aravind R. Reddy, FRCOphth, FRCSEd,j Pradeep Sharma, MD,k R. Michael Siatkowski, MD,l and Maria B. Yadarola, MDm The Accreditation Council for Graduate Medical Education (ACGME) requires US residency programs to assess ophthalmology residents for competency in 6 core areas. Ophthalmic surgical skills are currently part of the ACGME “Patient Care” competency, although some have advocated for a seventh competency, “Surgical Skills.” The Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery in Resident Training (OSCAR:Strabismus) tool was designed to aid in the assessment of surgical skills using procedure specific behavioral anchors. The present study evaluated inter-rater
Author affiliations: aAbrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH; cCincinnati Eye Institute, Cincinnati, OH; dHadassah Hebrew University, Jerusalem, Israel; eDepartment of Ophthalmology, Ankara University, Faculty of Medicine, Ankara, Turkey; fUniversity of Queensland, Brisbane, Queensland; gStrabismus Department, Instituto de Oftalmologia Fundacion Conde de Valenciana, Mexico; h Children’s Mercy Hospital, Kansas City, Missouri; iDepartment of Ophthalmology, Bradford Royal Infirmary, Bradford, UK; jDepartment of Ophthalmology, Royal Aberdeen Children’s Hospital and University of Aberdeen, Aberdeen, Scotland; kRP Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; lDean McGee Eye Institute, University of Oklahoma, Norman, OK; mDepartment of Pediatric Ophthalmology and Adult Strabismus, Centro de Ojos Romagosa, Cordoba, Argentina Supported in part by a Challenge Grant from Research to Prevent Blindness, Inc to the University of Cincinnati Department of Ophthalmology (James J. Augsburger, MD, Chairman). Research to Prevent Blindness, Inc had no role in the design or conduct of this research. Presented in part as a poster at the Annual Meeting of the American Academy of Ophthalmology, New Orleans, Louisiana, November 16-19, 2013. Submitted September 8, 2015. Revision accepted December 31, 2015. Correspondence: W. Walker Motley, III, MS, MD, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 4008, Cincinnati, OH 45229 (email: [email protected]). J AAPOS 2016;20:184-185. Copyright Ó 2016 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.12.007
Exemption was granted by the Institutional Review Board of Cincinnati Children’s Hospital Medical Center for this study, which conforms with all requirements of the US Health Insurance Portability and Accountability Act of 1996. Five video recordings of horizontal rectus muscle recession surgery performed by 5 different University of Cincinnati ophthalmology residents were distributed to 10 teaching faculty strabismus surgeons, who served as evaluators for this study. The 10 evaluators resided in 9 countries: Argentina, Australia, India, Israel, Mexico, Scotland, Turkey, the United Kingdom, and the United States. All evaluators are experienced strabismus surgeons who routinely train ophthalmology residents at academic institutions. Each evaluator assessed the performance of horizontal rectus recession by each resident using the OSCAR:Strabismus tool (available on the website of the International Council of Ophthalmology, https://www. icoph.org/downloads/ICO-OSCAR-Strabismus.pdf). The surgical steps that would be evaluated by using OSCAR:Strabismus elements 1, 14, and 17 could not be adequately recorded by the videography equipment in the operating room; therefore the evaluators were instructed to not score elements 1, 14, and 17 during their evaluations. Scored evaluations were analyzed for inter-rater agreement using the Cronbach a coefficient, which was computed for the tool as a whole and for the individual elements. A Cronbach a coefficient of $0.7 was considered to demonstrate satisfactory inter-rater agreement; of 0.9, excellent agreement.1 The Pearson correlation coefficient (r) was calculated to evaluate for correlation between OSCAR:Strabismus score and time required for a resident to complete a procedure.
Results Residents’ scores for each OSCAR:Strabismus element are shown in Appendix A (e-only). The mean total score for all 5 residents was 4.0 0.5 (standard deviation). Individual OSCAR:Strabismus element scores ranged from 2.8 to 5.0. Cronbach a coefficients for each OSCAR:Strabismus element as well as the Cronbach a coefficient for the tool as a whole are listed in Table 1. The OSCAR:Strabismus Cronbach a coefficient for the entire assessment tool was above 0.9, indicating excellent inter-rater agreement. When analyzed individually, the OSCAR assessment elements each demonstrated at least satisfactory inter-rater agreement (Cronbach a $ 0.7), with the exception of element 8. The mean time required to complete the surgical procedure was 29 7.1 minutes. The Pearson correlation coefficient for duration of procedure versus OSCAR:Strabismus score was 0.97.
Journal of AAPOS