Wilmer Institute Research Articles

The Readability of Ophthalmological Patient Education Materials Provided by Major Academic Hospitals

ABSTRACT Introduction The internet is an increasingly important resource for patients seeking health-related information. Because of this trend, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend that online patient education materials (PEMs) be written between a third and seventh grade level. The present study evaluates the readability levels of ophthalmological PEMs provided by five major academic hospitals, quantifies the availability of accompanying videos and graphics, and examines the extent to which readability may be increased. Methods In March 2021, 397 PEMs from five major academic hospitals were extracted for subsequent analysis by seven validated readability assessments. The presence of an accompanying video or graphic was noted. Statistical significance was assessed using the Kruskal-Wallis test with Dunn’s multiple comparisons test and the chi-square test. Results Nearly all articles were written above the recommended reading level of 7th grade. After averaging the scales for each article, the median grade level was 11.7 (interquartile range [IQR], 10.7–12.7). The PEMs with the highest median reading level were provided by the Johns Hopkins University Wilmer Institute (12.6, IQR, 11.3 – 13.6). Only 13.6% and 13.1% of articles had an accompanying video and graphic, respectively. Reduction of sentence length beneath 15 words resulted in an improvement of readability by 2.7 grade levels. Conclusions The readability of online patient resources provided by major academic hospitals were above the literacy guidelines recommended by the NIH and AMA. Furthermore, most articles did not include a video or graphic, both of which could potentially improve patient understandability of educational materials. By altering these PEMs, as demonstrated here, institutions could increase the value these articles provide for patients and therefore the quality of the patient-physician relationship.

James Finbarr (Barry) Cullen

James Finbarr Cullen (“Barry”) was one of the great names in ophthalmology, although he would never have thought that of himself. He qualified at University College Dublin in1952. After the...

Chi-Chao Chan: passion is very important for the success

Chi-Chao Chan ( Figure 1 ), M.D., an American board certified ophthalmologist, is a Scientist Emerita of the National Eye Institute (NEI), National Institutes of Health (NIH), USA. She studied at Zhongshan Medical College (now Sun Yat-sen University Medical School) in China [1961–1967], went to USA in 1968. In USA, Dr. Chan received both bachelor (BA, 1972) and medical doctorate (MD, 1975) degrees from Johns Hopkins University, completed ophthalmology residency at Stanford University Medical Center in 1979, and two post-doctorial fellowships at the Wilmer Institute, Johns Hopkins (ophthalmic pathology, 1979–1982) and at the NEI, NIH (clinical immunology, 1982–1986), respectively. She got tenured and became the Chief of Immunopathology Section in the Laboratory of Immunology and the Chief of Histopathology Core at NEI/NIH; became a world expert in ophthalmic pathology and ocular immunology.

Chi-Chao Chan: passion is very important for the success

Chi-Chao Chan ( Figure 1 ), M.D., an American board certified ophthalmologist, is a Scientist Emerita of the National Eye Institute (NEI), National Institutes of Health (NIH), USA. She studied at Zhongshan Medical College (now Sun Yat-sen University Medical School) in China [1961–1967], went to USA in 1968. In USA, Dr. Chan received both bachelor (BA, 1972) and medical doctorate (MD, 1975) degrees from Johns Hopkins University, completed ophthalmology residency at Stanford University Medical Center in 1979, and two post-doctorial fellowships at the Wilmer Institute, Johns Hopkins (ophthalmic pathology, 1979–1982) and at the NEI, NIH (clinical immunology, 1982–1986), respectively. She got tenured and became the Chief of Immunopathology Section in the Laboratory of Immunology and the Chief of Histopathology Core at NEI/NIH; became a world expert in ophthalmic pathology and ocular immunology.

Outcomes and Bleb-Related Complications of Trabeculectomy

To determine rates of success and complications of trabeculectomy surgery. Case series. Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008. By using the Wilmer Institute's billing database, we identified all patients at least 12 years of age coded as having undergone trabeculectomy between May 2000 and October 2008 by 1 of 2 glaucoma surgeons and whose surgery was not combined with another operation. From the chart, we abstracted demographic information on the patients and clinical characteristics of the eyes. The Kaplan-Meier product-limit method and Cox proportional hazard models were used to look at success rates and characteristics associated with inadequate intraocular pressure (IOP) reduction. Complications were tabulated. (1) Success rate of trabeculectomy, as determined by the achievement of each of 4 different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications. During the study period, 797 eyes of 634 persons underwent trabeculectomy without concurrent surgery. The success rates 4 years after surgery, with or without the use of IOP-lowering eye drops, were 70%, 72%, 60%, and 44%, for achievement of target IOP, ≤18 mmHg and ≥20% IOP reduction, ≤15 mmHg and ≥25% reduction, and ≤12 mmHg and ≥30% reduction, respectively. Increased chance of success was associated with European-derived race; use of mitomycin C (MMC); higher concentrations of MMC, when used; and higher preoperative IOP. Age and previous intraocular surgery were not associated with surgical success. Complications included worsening lens opacity in 242 of 443 phakic eyes (55%), loss of ≥3 lines of acuity (Snellen) in 161 eyes (21%), surgery for bleb-related problems in 70 eyes (8.8%), and infection occurring >6 weeks after surgery in 27 eyes (3.4%). A total of 101 eyes of 94 patients had at least 1 subsequent operation for inadequate IOP control. Trabeculectomy surgery performed by 2 experienced glaucoma specialists achieved target IOP at 4 years in 70% of those operated and was associated with progressive cataract and small risks of bleb-related complications. These results are comparable to those reported in smaller series.

Professor Gerard Crock AO

Professor Gerard William Crock (AO 1985, KStJ 1990, MB BS, FRCS, FRACS, FRACP, FRANZCO) died peacefully at home on 23 December 2007. He was a compassionate and considerate physician, an...

Age-related Macular Degeneration Histopathologic Studies

From the Eye Pathology Laboratory, Wilmer Institute, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore. Originally received: November 9, 1992. Revision accepted: March 30, 1993. Presented in part at the Combined Meeting of the American Association of Ophthalmic Pathologists with the American Academy of Ophthalmology, Dallas, November 9, 1992. Supported in part by core grant EY 01765-11 from the National Eye Institute, National Institutes of Health, Bethesda, Maryland, The Macula Foundation, Inc, New York, New York, and The Richard H. Chartrand Foundation, Burlingame, California. Reprint requetss to W. Richard Green, MD, Eye Pathology Laboratory, Maumenee Bldg 427, Johns Hopkins Hospital, 600 North Wolfe St, Baltimore, MD 21287-9248.

The Dragged-Fovea Diplopia Syndrome: Clinical Characteristics, Diagnosis, and Treatment

To identify the clinical characteristics of the dragged-fovea diplopia syndrome, to introduce a simple diagnostic test that aids in the evaluation of such patients, and to provide a simple treatment option to improve the diplopia in some of these patients. Retrospective, observational case series. Ninety-five affected eyes in 83 consecutive patients seen between January 1, 1993, and August 9, 2004, who were diagnosed with the dragged-fovea diplopia syndrome at one institution. We reviewed the records of 222 patients who have been seen in the Krieger Children's Eye Center at The Wilmer Institute since 1993 with a diagnosis of maculopathy, internal limiting membrane, or dragged fovea. We collected ocular findings and history for those patients who reported binocular diplopia that was not amenable to prism therapy and not secondary to acquired strabismus. We recorded the presence of metamorphopsia on Amsler grid testing or other clinical evidence of macular wrinkling, response to prism trial, response to the small-field central fusion test (lights on-off test), and response to partial occlusion with Scotch Satin tape (3M Co., St. Paul, MN). Ninety-five affected eyes in 83 patients met the criteria for inclusion in the study. All patients who were tested with the lights on-off test (n = 69) responded positively, demonstrating rapid central fusion with room lights off, and recurrence of central diplopia with peripheral fusion with room lights on. Forty-six patients (of 64 tested) were receptive to monocular occlusion with Scotch Satin tape. The dragged-fovea diplopia syndrome consists of central diplopia in the presence of peripheral fusion, secondary to dragging of the fovea in one or both eyes by retinal disease. The central diplopia cannot be eliminated by prism therapy or eye muscle surgery. The lights on-off test has proved pathognomonic for this syndrome, and many patients have benefited from partial monocular occlusion with Scotch Satin tape.

Survey of complications and recommendations for management in dissatisfied patients seeking a consultation after refractive surgery

To review complications associated with and management options for dissatisfied patients seeking a consultation after refractive surgery performed elsewhere. Refractive Eye Surgery Center, The Wilmer Institute, Lutherville, Maryland, USA. In this retrospective review, charts of consecutive dissatisfied patients who sought a refractive consultation between June 1999 and January 2003 after refractive surgery performed elsewhere were reviewed and the following parameters were analyzed: visual acuity (uncorrected and best spectacle corrected), prior manifest refraction, complications, and recommendations. The subjective complaints, complications, and visual acuity were reviewed, and the associated historical or visual risk factors as well as treatment options were analyzed. One hundred sixty-one eyes in 101 patients with ocular complaints were identified. One hundred thirty-four eyes (83.2%) had had laser in situ keratomileusis; 22 eyes, photorefractive keratectomy; 4 eyes, radial keratotomy; and 1 eye, laser thermokeratoplasty. The most common subjective complaints were blurred distance vision (59.0%), glare and night-vision disturbances (43.5%), and dry eyes (21.1%). The most common complications were overcorrection (30.4%), irregular astigmatism (29.8%), dry eyes (29.8%), glare (26.1%), difficulty with night driving (16.7%), and corneal haze (16.7%). The most common cause identified in eyes with best spectacle-corrected visual acuity worse than 20/40 was irregular astigmatism (10 of 18 eyes [55.5%]). The most common recommendation for management was medical treatment or observation (68.3%). Medical therapies recommended included lubrication, punctal plugs, topical and systemic pharmaceutical agents to modulate ocular surface, spectacles, and contact lenses. Keratoplasty (lamellar or penetrating) was recommended in 4 patients (4 eyes [2.5%]). The diagnoses included corneal ectasia in 3 eyes and severe flap complication with irregular astigmatism in 1 eye. Nine patients (5.6% eyes) required nonkeratoplasty surgery. In other patients, waiting for advances in technology, including wavefront-guided customized retreatment, was recommended. A spectrum of complications associated with refractive surgery may result in patient dissatisfaction. Proper patient selection, prevention strategies, and prompt diagnosis and medical or surgical intervention may be beneficial in managing complications and improving patient satisfaction.

Malignant Glaucoma, An Enigma Solved?

Edward Maumenee Professor of Ophthalmology Wilmer Institute Johns Hopkins University Baltimore, Maryland

Advances in glaucoma medication during the 1990s and their effects.

Glaucoma Service and Dana Center for Preventive Ophthalmology, Wilmer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland Address correspondence and reprint requests to Dr. Harry A. Quigley, Glaucoma Service and Dana Center for Preventive Ophthalmology, Johns Hopkins Hospital/Wilmer Institute, 600 N. Wolfe St., Wilmer Room 122, Baltimore MD 21287.

Cataract surgery by phacoemulsification in adults with retinopathy of prematurity

PURPOSE: To report the preoperative, operative, and postoperative factors associated with phacoemulsification cataract surgery in adults with retinopathy of prematurity. METHODS: Records of patients with retinopathy of prematurity who underwent phacoemulsification at The Wilmer Institute between January 1990 and January 2000 were retrospectively searched. Seventeen adults (9 women, 8 men) with retinopathy of prematurity were identified who had undergone phacoemulsification for visually significant cataract or phacomorphic glaucoma and who had at least 6 months of postoperative follow-up. RESULTS: Cataract extraction by phacoemulsification was performed on 20 eyes. Follow-up ranged from 6 to 103 months (mean, 32 months). A posterior chamber intraocular lens was placed in 18 eyes; two eyes were left aphakic for refractive reasons. Zonular weakness was noted in two eyes in which the intraocular lens was suture fixated to the sclera. Concomitant trabeculectomy was performed in one eye. Visual acuity improved in 18 of 20 eyes and remained unchanged in two eyes. Postoperatively, visual acuity was worse than 5/200 in two eyes, 5/200 to worse than 20/100 in five eyes, 20/100 to 20/50 in five eyes, and 20/40 or better in eight eyes. One eye developed a rhegmatogenous retinal detachment 1 month after cataract surgery; the retina was successfully reattached. CONCLUSIONS: Although cataract extraction in eyes with regressed retinopathy of prematurity may present challenges, such as high myopia, monocularity, glaucoma, and previous ocular surgery, phacoemulsification in this series proved to be relatively safe as well as visually rehabilitating. The surgeon should be aware of the special considerations in this population, alert to potential zonular weakness intraoperatively, and careful of increased postoperative risks, including retinal detachment.

RETINAL DETACHMENT IN MARFAN SYNDROME

Purpose: To report postsurgical findings in patients with Marfan syndrome and retinal detachment (RD). Methods: The authors identified and retrospectively reviewed the charts of one cohort of 12 patients (15 eyes) with Marfan syndrome and RD who were operated on at the Wilmer Institute and a second cohort of 16 such patients (24 eyes) who were operated several years earlier and elsewhere. Results: First cohort—Final visual acuity (VA) was 20/80 or better and the retina was flat in all five phakic eyes (100%). The RD occurred after the eye had undergone lens removal in 10 eyes, 6 of which (60%) had a final VA of 20/80 or better, and 9 of which (90%) had a final VA of 5/200 or better (P = 0.20). Second cohort—The final VA was 20/80 or better and the retina was flat in 6 of the 7 phakic eyes (86%). Among 17 aphakic or pseudophakic eyes, only 5 (29%) had a flat retina and VA of 20/80 or better, whereas 12 (71%) had no light perception (P = 0.03). Conclusions: The results of RD operations done in the past in Marfan patients were worse when the eye was aphakic. In most cases operated more recently, the prognosis for successful RD repair was good regardless of whether the eye was phakic. RETINA 20:358-363, 2000

Bleb reduction and bleb repair after trabeculectomy

Objective To describe methods and outcomes for repair of bleb-related complications of trabeculectomy surgery. Design Retrospective, consecutive, noncomparative case series. Participants Thirty-one persons having bleb revision by two surgeons at the Wilmer Institute from 1994 to the present. Intervention One of two types of revision surgery was performed: bleb reduction to decrease symptoms from large blebs or bleb repair to improve hypotony, using conjunctival rotation flap or free conjunctival autograft. Main outcome measures Visual acuity, intraocular pressure (IOP), reported symptoms, complications, and number of glaucoma medications at the final visit. Results The mean time from trabeculectomy to bleb revision was 4.4 years. Bleb reduction was performed because of symptomatic, high blebs in 11 eyes of 11 persons. Bleb repair was performed to end bleb leakage in 13 eyes of 13 persons and to increase IOP in 8 eyes of 7 persons with hypotony. Median visual acuity improved from 20/50 before revision to 20/30 at most recent follow-up. Mean IOP increased after treatment from 7.7 ± 4.9 to 12.4 ± 4.0 mmHg ( P < 0.001). Symptoms that caused the revision surgery were eliminated in all cases. None of these eyes has lost IOP control, none has required repeat trabeculectomy, and only 2 of the 32 (6%) require topical glaucoma medication. More than one revision procedure was required in 8 of 32 (25%) eyes. Conclusions Surgical bleb revisions for complications after trabeculectomy surgery are safe and effective. Bleb reduction for large, symptomatic blebs or bleb repair for leaking blebs and hypotony did not lead to loss of IOP control.

In memoriam: A. Edward Maumenee, Jr., MD 1913–1998

In memoriam: A. Edward Maumenee, Jr., MD 1913–1998

Current and Future Approaches to Glaucoma Screening

Glaucoma Service and Dana Center for Preventive Ophthalmology, Wilmer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A.

Frequency of ocular metastases in patients dying of cancer in eye bank populations.

To examine the frequency of intraocular metastases in patients who had died of cancer, in an eye bank and necropsy population sample. The first group included 302 cancer cases received from the Wisconsin Eye Bank between 1988 and 1993. In the second group, ocular pathology records at the Wilmer Institute from 1976 to 1980 were analysed for ocular metastases in necropsy subjects dying of cancer. Nonocular cancer was the cause of death in 741 cases; among these, 510 were attributed to carcinomas. In the Wisconsin Eye Bank group, three cases (1%) had gross metastases. Out of 255 carcinoma cases, one (0.4%) had gross metastases. In the Wilmer Institute group, gross metastases were observed in 35 (4.7%) cases. Of the 510 patients dying of carcinomas, six (1.2%) had macroscopic metastases. Ocular metastases were detected histopathologically in 93 of 741 (12.6%) of cases. Even though it is difficult to assess the true frequency of ocular metastases in patients dying of cancer, the answer to this question was attempted by determining the frequency of ocular metastasis in patients who died of cancer and who donated their eyes to the Wisconsin Eye Bank or had postmortem examination at the Johns Hopkins Hospital. Microscopic metastases were found in 12.6% of cases. The frequency of gross metastases has decreased over the past 12 years from 4.7% to 1% (p value = 0.005) owing to improved treatment of leukaemia; however, the frequency of macroscopic metastases due to carcinomas has not changed (p value = 0.38).

CHOROIDAL RUPTURE

Choroidal ruptures occurring as a result of blunt ocular injury are uncommon. A 72-year-old woman sustained blunt trauma to the left eye in 1965. In 1986, she was seen at the Wilmer Institute, and posterior choroidal rupture was documented and fluorescein angiography was performed. Absence of fluorescence was seen in the area of the rupture, and the inferotemporal artery and vein dipped into the area and emerged on the other side of the rupture. The eyes were obtained postmortem, and histologic examination was performed. Examination of the left eye revealed a horizontal linear white scar inferior to the optic nerve and macula. Stepped-serial sections through the rupture revealed a 0.7-mm wide defect in Bruch's membrane and retina where fibrous tissue containing melanocytes extended into the vitreous cavity for a short distance. The clinicopathologic features of an indirect horizontal choroidal rupture is reported.

Review of: A Link With Our Past: An Interview with A. Edward Maumenee, M.D.

Reviewed by: A Link with Our Past: An Interview with A. Edward Maumenee, M.D. Ronald S. Fishman A. Edward Maumenee. A Link with Our Past: An Interview with A. Edward Maumenee, M.D. Interview conducted in 1990 by Sally Smith Hughes. Ophthalmology Oral History Series, no. 8. San Francisco: Foundation of the American Academy of Ophthalmology, and Berkeley: Regional Oral History Office, University of California at Berkeley, 1994. xxx + 267 pp. Ill. $45.00 (paperbound). A. Edward Maumenee wanted to become the best ophthalmologist in the world, he said when he was a resident in 1939, and he certainly became one of the most renowned. Director of the Wilmer Institute of the Johns Hopkins Hospital from 1955 to 1979, he was able to select, train, and inspire outstanding residents and fellows—many of whom made careers in academic ophthalmology, became heads of academic departments themselves, and maintain a high regard for him. He made significant contributions to the understanding and treatment of eye disease and was instrumental in the birth of the National Eye Institute of the NIH. He played on a world stage, with leadership roles in almost all the national and international groups of organized ophthalmology. This volume is the eighth in a series of oral biographies sponsored by the American Academy of Ophthalmology and meant to preserve the memories of some of its most distinguished members before the colors fade. These men, largely trained before the Second World War, represent the last generation of generalists, from the period when it was still a reasonable ideal for a gifted ophthalmologist to be accepted as an authority in more than one subspecialty. The great advantage of the oral biography format is its immediacy and informality. The reader is effectively there in the room across the cocktail table from the distinguished subject, hearing him reminisce about his career and the changes he has seen. The interviewer, Sally Hughes, is a professional historian, knowledgeable about the personalities of the era, and invariably tactful and polite, so the interviews have all the constraints of a social occasion. How revealing, in fact, are they? Do not look here for a well-rounded consideration of the science involved. Do not hunt here for the skeletons in the closet. On the other hand, for the reader who has enough familiarity with the subject and his environment to read between the lines, there are anecdotes that give insights not obtainable elsewhere. It is unlikely, for instance, that any institutional history will ever give the pointed views that Maumenee provides on the splitting off of eye disease from the National Institute of Neurological Diseases and Blindness with the formation of the National Eye Institute, multiplying many times the funds available for blindness research. As source material, undocumented oral history is limited in scope and occasionally in accuracy. What it does provide unequivocally is what the distinguished subject himself remembers at the end of a distinguished career, together with a clear demonstration, for anyone who had doubts about it, that medicine is an intensely human enterprise. Ronald S. Fishman Washington Hospital Center, Washington, D.C. Copyright © 1996 The Johns Hopkins University Press

Cigarette smoking and risk for progression of nuclear opacities.

To examine the relationships between smoking and the 5-year incidence of new nuclear opacities and between smoking and the progression of nuclear opacities in a prospective study of a cohort of Chesapeake Bay watermen. A total of 442 men (age, > or = 30 years in 1985) with paired, gradable lens photographs in at least one eye in both 1985 and 1990 were studied. Photographs were graded by two readers who used the grading scheme of the Wilmer Institute, Baltimore, Md, with severity ranging in decimal units between 0.0 and 4.0. Data on the smoking history of the subjects were collected by personal interviews that were conducted in 1985 and updated in 1990. The incidence and progression of opacities increased with age. A nonsignificant association was observed between smoking (for both current and ex-smokers) and the incidence of a nuclear opacity. The risk of progression of nuclear opacities of less than grade 3 at baseline to grade 3 or worse was 2.4-fold higher among current smokers in 1985, compared with that among ex-smokers and nonsmokers (95% confidence limits: 1.0, 6.0) after adjustment for age, baseline opacity status, and alcohol use. An 18% increased risk of progression was significantly associated with each pack-year that a subject smoked between 1985 and 1990. These data confirm previous findings that smoking is associated with a nuclear opacity, particularly with progression to severe opacities.