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Figure 2. Optical Coherence Tomographic Images Showing Corneal and Lens Opacification A

B

Optical coherence tomographic images of the corneal opacification (arrowhead) (A) and the presumed bee stinger associated with lens opacification (arrowhead) (B).

The inactivation of the toxins after the acute phase and the volume of the bee venom could explain the absence of inflammatory reaction.1 Although there is controversy regarding the ideal approach to retained bee and wasp stingers,6 we decided not to remove it because no signs of intraocular inflammation were found. Moreover, the patient was satisfied with his visual acuity and refused to undergo phacoemulsification. We opted to schedule annual eye examination with further cataract surgery when visual acuity decreases to a point that causes dissatisfaction. Alex Sá, MD Sigrid Arruda, MD Marcos J. Cohen, MD João M. Furtado, MD, PhD

Additional Contributions: Solange R. Salomão, PhD, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil, and Vera Lucia Imperatriz-Fonseca, PhD, Universidade de São Paulo, São Paulo, Brazil, helped with the description of the stinger; they received no compensation. 1. Gilboa M, Gdal-On M, Zonis S. Bee and wasp stings of the eye: retained intralenticular wasp sting: a case report. Br J Ophthalmol. 1977;61(10):662-664. 2. Arcieri ES, França ET, de Oliveria HB, De Abreu Ferreira L, Ferreira MA, Rocha FJ. Ocular lesions arising after stings by hymenopteran insects. Cornea. 2002;21 (3):328-330. 3. Maltzman JS, Lee AG, Miller NR. Optic neuropathy occurring after bee and wasp sting. Ophthalmology. 2000;107(1):193-195. 4. Chauhan D. Corneal honey bee sting: endoilluminator-assisted removal of retained stinger. Int Ophthalmol. 2012;32(3):285-288. 5. Shorter JR, Rueppell O. A review on self-destructive defense behaviors in social insects. Insectes Soc. 2012;59(1):1-10. doi:10.1007/s00040-011-0210-x.

Author Affiliations: Instituto de Olhos de Manaus, Manaus, Brazil (Sá, Arruda, Cohen); Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil (Furtado); Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil (Furtado). Corresponding Author: João M. Furtado, MD, PhD, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Av Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil 14049-900 ([email protected]). Published Online: November 6, 2014. doi:10.1001/jamaophthalmol.2014.4353. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: This work was supported by Sight First Grant 1758 from the Lions Club International Foundation and by Fundação de Amparo à Pesquisa do Estado de São Paulo. Dr Furtado was supported by the Programa Ciência sem Fronteiras postdoctoral scholarship from Conselho Nacional de Pesquisa e Desenvolvimento Tecnológico. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of jamaophthalmology.com

the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

6. Roomizadeh P, Razmjoo H, Abtahi MA, Abtahi SH. Management of corneal bee sting: is surgical removal of a retained stinger always indicated? Int Ophthalmol. 2013;33(1):1-2.

COMMENT & RESPONSE

Teaching Ophthalmoscopy to Medical Students To the Editor We read with great interest the recent article by Byrd et al1 presenting an innovative method to improve ophthalmic training in medical school. They reported that medical students who voluntarily participated in a community service project (CSP) dedicated to ophthalmic care for the underserved had increased ophthalmology knowledge and short- and long-term direct ophthalmoscopy skills assessed by matching a patient’s fundus to 1 of 4 fundus photographs. Longterm ophthalmoscopy skills were reportedly higher in the CSP group, even without additional skill reinforcement. Although this pilot study included a small number of participants and the possibility of bias from the self-selection of more (Reprinted) JAMA Ophthalmology February 2015 Volume 133, Number 2

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motivated ophthalmology learners in the CSP group, we hope these results will be helpful in furthering the important missions of improving ophthalmic care to the underserved and improving undergraduate ophthalmology education. We and others have demonstrated that medical students’ direct ophthalmoscopy skills decrease over time without longitudinal skill reinforcement, signaling the importance of medical school curriculum reform to facilitate increased longitudinal exposure to ophthalmoscopy.2-4 In a study of 119 first-year medical students, Kelly et al5 assessed the use of fundus photographs in medical education in the Teaching Ophthalmoscopy to Medical Students (TOTeMS) study and compared the accuracy and preferences of medical students using direct ophthalmoscopy and fundus photographs. Students were more accurate and preferred using fundus photographs over direct ophthalmoscopy. In a 1-year follow-up study (TOTeMS II)2 of 107 of the students who participated in the original TOTeMS study, we demonstrated that the increased accuracy and student preference for fundus photographs over direct ophthalmoscopy persisted after 1 year, with no additional training. However, both the direct ophthalmoscopy and fundus photograph groups performed worse than 1 year prior, likely related to a lack of interim fundus examination skill reinforcement. Indeed, the self-reported median frequency of fundus examination during a general physical examination was less than 10%, and 20% of students cited discouragement from their preceptor as the primary reason for omitting a fundus examination. Certainly, continuing efforts are needed to combat the rising tide of indifference to ocular fundus examination in medical education and clinical practice. As innovative methods such as immersion experiences in ophthalmology-based CSPs and the increasing availability of nonmydriatic fundus cameras have the potential to infuse enthusiasm for ocular fundus examination into medical education, there is hope for the future of ophthalmoscopy.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Byrd JM, Longmire MR, Syme NP, Murray-Krezan C, Rose L. A pilot study on providing ophthalmic training to medical students while initiating a sustainable eye care effort for the underserved. JAMA Ophthalmol. 2014;132(3):304-309. 2. Mackay DD, Garza PS, Bruce BB, et al. Teaching ophthalmoscopy to medical students (TOTeMS) II: a one-year retention study. Am J Ophthalmol. 2014;157 (3):747-748. 3. Lippa LM, Boker J, Duke A, Amin A. A novel 3-year longitudinal pilot study of medical students’ acquisition and retention of screening eye examination skills. Ophthalmology. 2006;113(1):133-139. 4. Mottow-Lippa L, Boker JR, Stephens F. A prospective study of the longitudinal effects of an embedded specialty curriculum on physical examination skills using an ophthalmology model. Acad Med. 2009;84(11): 1622-1630. 5. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS study). Am J Ophthalmol. 2013;156(5):1056-1061, e10.

Occlusion Caused by Cosmetic Facial Filler Injection

Funding/Support: This work was supported in part by an unrestricted departmental grant to the Department of Ophthalmology, Emory University School of Medicine from Research to Prevent Blindness and by core grant P30-EY06360 to the Department of Ophthalmology, Emory University School of Medicine from the National Eye Institute. Dr Newman was supported by the

To the Editor We read with interest the recent article by Carle et al1 describing cases of central retinal artery occlusion caused by cosmetic facial filler injection. However, we would like to point out some issues in 2 aspects regarding this article. First, they purported that this was the first report regarding blindness caused by filler injected into the forehead. However, our group previously reported 12 cases of cosmetic facial filler injection–related retinal artery occlusion2 and, more recently, 44 cases of nationwide survey results.3 Most were young women, and the glabella was the most commonly injected site. In our articles, the injection sites were mainly classified as glabella, nasolabial fold, or nasal dorsum for rhinoplasty. Injections in the forehead region were included in the glabella category for the following reasons. Many young patients received forehead and glabellar filler injections simultaneously with the purpose of augmenting or reshaping the forehead4,5 rather than simply improving a frown line in the glabella, which occurs as an aging process. Moreover, the presumed entry site for retrograde embolism in the glabella and forehead region may be the same artery, ie, the supratrochlear or supraorbital artery,2 which suggests that the glabella and forehead should be regarded as the same etiological region regarding cosmetic facial filler–associated retinal artery occlusion. Therefore, blindness caused by filler injection in the forehead is not a new finding but one that has already been reported in the literature even though it is roughly described as the glabella region. Second, they stated that cosmetic facial filler injection into the forehead is an off-label use and safety approved only in specific regions such as the nasolabial fold. This statement leads to misconception that nasolabial fold injection does not harbor the risk of retinal artery occlusions or at least that it is a safer region compared with the glabella or the forehead region. However, we noticed considerable cases of ophthalmic artery occlusion and occlusion of its branches that occurred after nasolabial injections (11 of 44 cases [25%] underwent nasolabial fold injections, 7 of which underwent nasolabial in-

JAMA Ophthalmology February 2015 Volume 133, Number 2 (Reprinted)

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Devin D. Mackay, MD Beau B. Bruce, MD, MS Nancy J. Newman, MD Valérie Biousse, MD Author Affiliations: Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia (Mackay, Bruce, Newman, Biousse); Department of Epidemiology, Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, Georgia (Bruce); Department of Neurology, Emory University School of Medicine, Atlanta, Georgia (Bruce, Newman, Biousse); Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia (Newman). Corresponding Author: Beau B. Bruce, MD, MS, Neuro-Ophthalmology Unit, Emory Eye Center, Emory Clinic, 1365-B Clifton Rd NE, Atlanta, GA (bbbruce @emory.edu). Published Online: October 23, 2014. doi:10.1001/jamaophthalmol.2014.4235. Conflict of Interest Disclosures: None reported.

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Lew R. Wasserman Merit Award from Research to Prevent Blindness. Dr Bruce was supported by grant K23-EY019341 from the National Eye Institute.

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Teaching ophthalmoscopy to medical students.

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