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902
Letters to the Editor
treatment and the absence of blebitis and intraocular inflammation make infective endophthalmitis as a cause of corneal decompensation unlikely.5 Although late bleb needling with MMC 0.01% is considered a safe and effective procedure, we report a rare case of corneal decompensation that resolved spontaneously.
Erica Darian-Smith1,2 and Tze’Yo Toh FRANZCO2,3,4 1 Launceston Clinical School, University of Tasmania, 2 Tasmanian Eye Institute, 3The Eye Hospital and 4 Launceston Eye Institute, Launceston, Tasmania, Australia Received 26 March 2014; accepted 31 March 2014.
REFERENCES 1. Maestrini HA, Cronemberger S, Matoso HD et al. Late needling of flat filtering blebs with adjunctive mitomycin C: efficacy and safety for the corneal endothelium. Ophthalmology 2011; 118: 755–62. 2. Mietz H, Roters S, Krieglstein GK. Bullous keratopathy as a complication of trabeculectomy with mitomycin C. Graefes Arch Clin Exp Ophthalmol 2005; 243: 1284–7. 3. Cardozo A, Passos AF. Corneal complication after episcleral needling and subconjunctival injection of mitomycin-C associated with bupivacaine and adrenaline: considerations about the drug toxicity. Rev Bras Oftalmol 2005; 64: 272–9 (in Portuguese). 4. Holland SP, Morck DW, Lee TL. Update on toxic anterior segment syndrome. Curr Opin Ophthalmol 2007; 18: 4–8. 5. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW Jr. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol 1996; 114: 943–9.
Ophthalmology education in Australian medical schools: a survey of Australian junior medical officers Ophthalmic presentations to the emergency department are common, and junior doctors who are often the first to review these patients may be required to determine whether an ophthalmology referral is required.1,2 In addition, at least 3% (estimated range 3–19%) of all primary care consultations involve eye-related conditions,1,3 and ocular manifestations of systemic disease are common. The average time spent learning ophthalmology in Australian medical schools takes up less than 2% of university curricula,3,4 Competing/conflicts of interest: No stated conflict of interest. Funding sources: This paper was funded by a $1000 grant given by the Tasmanian Branch of the Royal Australian and New Zealand College of Ophthalmologists .
underrepresentative when considering the frequency of ophthalmology-related presentations in all clinical settings. The aim of this study was to evaluate junior medical officer perspectives on ophthalmology learning during medical school and perceived ophthalmology competency. Ophthalmology curricula within Australian universities have been investigated previously4; however, outcomes of teaching programmes have not been formally evaluated. An online questionnaire using SurveyMonkey (SurveyMonkey Inc., Palo Alto, CA, USA) was emailed to 1374 Australian interns within 29 Australian hospital networks. Questions related to the content of ophthalmology taught in Australian medical school curricula and the settings in which ophthalmology was learned. Clinical skills considered were those defined as important by either the Australian Curriculum Framework for Junior Doctors or in the curriculum suggested by the International Council of Ophthalmology. Responses were collected between February and October 2013. Graduates from non-Australian universities were excluded from analysis. The study conformed to the Declaration of Helsinki and its subsequent revisions, and was approved by the Tasmanian Human Research and Ethics Committee (HREC Approval No. H0013204). Results were analysed by SPSS 21 (IBM, Armonk, New York, USA). Descriptive statistics were run to describe data distributions. Pearson’s chi-square test was utilized for the investigation of associations between categorical variables. Differences in self-rated skill competencies and self-rated ability to diagnosed ophthalmological conditions were compared in respondents who had non-clinical only versus those with clinical exposure to ophthalmology using the Mann–Whitney U-test. Exposure to ophthalmology in an ophthalmology or other clinical rotation, operating theatre or ophthalmology elective was defined as clinical exposure. All tests were two sided and differences were accepted at P < 0.05 significance level. From 1374 distributed surveys, there were 348 responses, giving a response rate of 25.3%. All Australian medical schools were represented in responses. Two hundred and twelve respondents (60.9%) were female. The mean age of participants was 26.5 years, and there was no difference between genders (P = 0.314). Two hundred and eighty-nine (83%) respondents reported learning in lectures, 203 (58.3%) in small-group tutorials, 166 (47.7%) in a dedicated ophthalmology rotation, 95 (27.3%) in operating theatre sessions, 74 (21.3%) in other clinical rotations and 12 (3.4%) in research involvement. Ninety-two per cent (n = 320) of respondents identified that learning ophthalmology in medical school was important to prepare for medical internship, but only 38.5% (n = 134) stated that they had learnt enough to prepare themselves personally for their internship. Less than 19% of respondents who reported learning ophthalmology only in lectures felt that they learnt enough ophthalmology to carry out their internship year competently. Exposure to certain individual learning opportunities was associated with a higher likelihood of respondents reporting learning enough ophthalmology than those without the opportunity, specifically an ophthalmology rotation (50.3% vs. 28.3%,
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Letters to the Editor
903
Figure 1. Median self-rated ability to diagnose sight or lifethreatening conditions of respondents with only non-clinical exposure (lectures and small-group tutorials) compared with those with exposure in clinical settings.
Respondents with clinical exposure (n = 208) Respondents without clinical exposure (n = 84) Penetrating eye injury (0.08) Corneal abrasion (0.73)
Condition
Giant cell arteritis (0.32) Herpes simplex keratitis (P = 0.001) Acute closed angle glaucoma (0.06) Papilloedema (P = 0.005) Retinal detachment (P = 0.024) Central retinal artery occlusion (P = 0.004) Retinal vein occlusion (P < 0.0001) 0
2
4
6
8
10
Self-rated ability to diagnose (scale 0–10)
Figure 2. Median self-rated ability to perform ophthalmic clinical skills of respondents of exposure with only non-clinical exposure (lectures and small-group tutorials) compared with those with exposure in clinical settings.
Respondents without clinical exposure (n = 208) Respondents with clinical exposure (n = 84) Visual acuity testing (0.06) Pupillary light reflex assessment (0.56) Visual fields (0.46) Extraocular muscle motility assessment (0.14)
Clinical skill
Pupillary dilatation (0.48) Appropriate ophthalmology referral (P = 0.008) Staining and examining the cornea with fluorescein (P = 0.012) Fundoscopy (P = 0.001) Complete ocular history (P = 0.001) Slit-lamp examination (P = 0.033) Intraocular pressure measurement (P = 0.013) Anterior chamber depth assessment (P = 0.021) 0
P < 0.0001), ophthalmology research (75% vs. 37.5%, P = 0.013), operating theatre exposure (47.4% vs. 35.6%, P = 0.045) or small-group tutorials (43.3% vs. 32.4%, P = 0.04). Two hundred and ninety-two respondents completed the self-evaluation of ability to diagnose and perform clinical skills. Median self-rated ability of respondents with clinical exposure outside lectures and small-group tutorials was higher for diagnosis of all conditions and for most specific ophthalmic clinical skills (Figs 1,2).
2 4 6 8 Self-rated ability to perform (scale 0–10)
10
All individual clinical skills were deemed important by over 90% of the 292 respondents who completed the self-evaluation, except for anterior chamber depth (53% deemed important), intraocular pressure measurement (63%) and slit-lamp examination (83%). The vast majority of respondents (92%) indicated that learning in ophthalmology was important for internship; however, only 38.5% of these reported learning enough ophthalmology to prepare for being a junior doctor despite established university ophthalmology curricula4
© 2014 Royal Australian and New Zealand College of Ophthalmologists
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Letters to the Editor
compared with another study that found that 64% of Australian junior doctors felt well prepared for internship. Fifty-five per cent of the respondents felt unprepared for emergency medicine, and 21% felt unprepared for intensive care rotations.5 These findings are supported by anecdotal reports from the Australian Medical Education Study, in which focus groups including junior doctors and senior medical students frequently reported not learning enough surgical subspecialties, particularly ophthalmology.6 Results of this study suggest that existing educational programmes should be evaluated with a view of optimizing teaching outcomes while working within existing time constraints, which are unlikely to change. Importantly, teaching opportunities through clinical rotations were identified as a more effective learning experience and produced greater confidence in ophthalmic examination and diagnosis. Recent many medical school curricula have moved to a problems-based learning approach. This teaching method improves students’ learning and retention7; however, the learning model focuses on a core curriculum of common or serious diseases and has reduced the time available for teaching subspecialties, including ophthalmology.8 To work within this paradigm, incorporation of problems-based learning into ophthalmology teaching should be encouraged, particularly for core parts of the curricula, for example the evaluation of sight-threatening conditions. A similar concept to problems-based learning is computer-based learning, utilizing problems-based modules online. Although it cannot replace clinical experience, studies have been favourable and it may be useful in optimizing students’ clinical learning of ophthalmology,9 without limitations of available human resources and time constraints. Limitations to this study include a possible selection bias with the response rate (25.3%) and voluntary nature of the survey, and subjective bias due to candidates varying ability to accurately self-evaluate. It is also possible that respondents inaccurately answered questions based on knowledge or skills learnt, following graduation from medical school. Ophthalmology education is an important part of medical school, and junior doctors are commonly required to evaluate ophthalmic conditions. Australian medical graduates have variable ophthalmology education and overall are not confident in approaching ophthalmic conditions or performing specific examinations. Broader teaching experiences should be encouraged and clinical ophthalmology rotations were identified as important by junior medical officers to improve their ophthalmic examination and diagnostic skills.
ACKNOWLEDGEMENTS We would like to acknowledge the Tasmanian Branch of the Royal Australian and New Zealand College of Ophthalmologists for providing a grant to enable completion of this study.
Allister R Howie,1,2 Robin G Abell MBBS,2 Erica Darian-Smith,1,2 Penelope L Allen PhD,2 Paul J McCartney FRANZCO3 and Brendan J Vote FRANZCO2 1 Launceston Clinical School, University of Tasmania, 2 Tasmanian Eye Institute, Launceston, and 3Hobart Eye Surgeons, Royal Hobart Hospital, Hobart, Tasmania, Australia Received 1 March 2014; accepted 8 March 2014.
REFERENCES 1. Vernon SA. Eye care and the medical student: where should emphasis be placed in undergraduate ophthalmology? J R Soc Med 1988; 81: 335–7. 2. Kumar NL, Black D, McClellan K. Daytime presentations to a metropolitan ophthalmic emergency department. Clin Experiment Ophthalmol 2005; 33: 586–92. 3. Stark D, Beinssen A, Morrey C. Ophthalmology in the undergraduate curriculum. A review in Queensland. Aust N Z J Ophthalmol 1992; 20: 297–303. 4. Fan JC, Sherwin T, McGhee CN. Teaching of ophthalmology in undergraduate curricula: a survey of Australasian and Asian medical schools. Clin Experiment Ophthalmol 2007; 35: 310–7. 5. Dent A, Crotty B, Cuddihy H et al. Learning opportunities for Australian prevocational hospital doctors: exposure, perceived quality and desired methods of learning. Med J Aust 2006; 184: 436–40. 6. Lawson M, Bearman M. Australian Medical Education Study Summary Report: Surveys, Focus Groups and Interviews. Melbourne, Vic: Department of Education, Science and Training, 2007. 7. Farrell TA, Albanese MA, Pomrehn PR Jr. Problembased learning in ophthalmology: a pilot program for curricular renewal. Arch Ophthalmol 1999; 117: 1223–6. 8. Williams G, Lau A. Reform of undergraduate medical teaching in the United Kingdom: a triumph of evangelism over common sense. Br Med J 2004; 329: 92–4. 9. Kuchenbecker J, Parasta AM, Dick HB. Internet-based teaching and learning in ophthalmology. Ophthalmologe 2001; 98: 980–4.
Ophthalmologists and cost uncertainty In many parts of regional Australia, ophthalmology services are provided on a visiting basis. Conceptually this is a great thing. It is highly commendable that Australian ophthalmologists get out of the comfort and convenience of their city-based practice to travel to “the bush” on a regular basis. For people who live in the country this is also a great thing. They can get world standard eye care and attention Competing/conflicts of interest: No stated conflict of interest. Funding sources: No stated funding sources.
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Copyright of Clinical & Experimental Ophthalmology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
902
Letters to the Editor
treatment and the absence of blebitis and intraocular inflammation make infective endophthalmitis as a cause of corneal decompensation unlikely.5 Although late bleb needling with MMC 0.01% is considered a safe and effective procedure, we report a rare case of corneal decompensation that resolved spontaneously.
Erica Darian-Smith1,2 and Tze’Yo Toh FRANZCO2,3,4 1 Launceston Clinical School, University of Tasmania, 2 Tasmanian Eye Institute, 3The Eye Hospital and 4 Launceston Eye Institute, Launceston, Tasmania, Australia Received 26 March 2014; accepted 31 March 2014.
REFERENCES 1. Maestrini HA, Cronemberger S, Matoso HD et al. Late needling of flat filtering blebs with adjunctive mitomycin C: efficacy and safety for the corneal endothelium. Ophthalmology 2011; 118: 755–62. 2. Mietz H, Roters S, Krieglstein GK. Bullous keratopathy as a complication of trabeculectomy with mitomycin C. Graefes Arch Clin Exp Ophthalmol 2005; 243: 1284–7. 3. Cardozo A, Passos AF. Corneal complication after episcleral needling and subconjunctival injection of mitomycin-C associated with bupivacaine and adrenaline: considerations about the drug toxicity. Rev Bras Oftalmol 2005; 64: 272–9 (in Portuguese). 4. Holland SP, Morck DW, Lee TL. Update on toxic anterior segment syndrome. Curr Opin Ophthalmol 2007; 18: 4–8. 5. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW Jr. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol 1996; 114: 943–9.
Ophthalmology education in Australian medical schools: a survey of Australian junior medical officers Ophthalmic presentations to the emergency department are common, and junior doctors who are often the first to review these patients may be required to determine whether an ophthalmology referral is required.1,2 In addition, at least 3% (estimated range 3–19%) of all primary care consultations involve eye-related conditions,1,3 and ocular manifestations of systemic disease are common. The average time spent learning ophthalmology in Australian medical schools takes up less than 2% of university curricula,3,4 Competing/conflicts of interest: No stated conflict of interest. Funding sources: This paper was funded by a $1000 grant given by the Tasmanian Branch of the Royal Australian and New Zealand College of Ophthalmologists .
underrepresentative when considering the frequency of ophthalmology-related presentations in all clinical settings. The aim of this study was to evaluate junior medical officer perspectives on ophthalmology learning during medical school and perceived ophthalmology competency. Ophthalmology curricula within Australian universities have been investigated previously4; however, outcomes of teaching programmes have not been formally evaluated. An online questionnaire using SurveyMonkey (SurveyMonkey Inc., Palo Alto, CA, USA) was emailed to 1374 Australian interns within 29 Australian hospital networks. Questions related to the content of ophthalmology taught in Australian medical school curricula and the settings in which ophthalmology was learned. Clinical skills considered were those defined as important by either the Australian Curriculum Framework for Junior Doctors or in the curriculum suggested by the International Council of Ophthalmology. Responses were collected between February and October 2013. Graduates from non-Australian universities were excluded from analysis. The study conformed to the Declaration of Helsinki and its subsequent revisions, and was approved by the Tasmanian Human Research and Ethics Committee (HREC Approval No. H0013204). Results were analysed by SPSS 21 (IBM, Armonk, New York, USA). Descriptive statistics were run to describe data distributions. Pearson’s chi-square test was utilized for the investigation of associations between categorical variables. Differences in self-rated skill competencies and self-rated ability to diagnosed ophthalmological conditions were compared in respondents who had non-clinical only versus those with clinical exposure to ophthalmology using the Mann–Whitney U-test. Exposure to ophthalmology in an ophthalmology or other clinical rotation, operating theatre or ophthalmology elective was defined as clinical exposure. All tests were two sided and differences were accepted at P < 0.05 significance level. From 1374 distributed surveys, there were 348 responses, giving a response rate of 25.3%. All Australian medical schools were represented in responses. Two hundred and twelve respondents (60.9%) were female. The mean age of participants was 26.5 years, and there was no difference between genders (P = 0.314). Two hundred and eighty-nine (83%) respondents reported learning in lectures, 203 (58.3%) in small-group tutorials, 166 (47.7%) in a dedicated ophthalmology rotation, 95 (27.3%) in operating theatre sessions, 74 (21.3%) in other clinical rotations and 12 (3.4%) in research involvement. Ninety-two per cent (n = 320) of respondents identified that learning ophthalmology in medical school was important to prepare for medical internship, but only 38.5% (n = 134) stated that they had learnt enough to prepare themselves personally for their internship. Less than 19% of respondents who reported learning ophthalmology only in lectures felt that they learnt enough ophthalmology to carry out their internship year competently. Exposure to certain individual learning opportunities was associated with a higher likelihood of respondents reporting learning enough ophthalmology than those without the opportunity, specifically an ophthalmology rotation (50.3% vs. 28.3%,
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Letters to the Editor
903
Figure 1. Median self-rated ability to diagnose sight or lifethreatening conditions of respondents with only non-clinical exposure (lectures and small-group tutorials) compared with those with exposure in clinical settings.
Respondents with clinical exposure (n = 208) Respondents without clinical exposure (n = 84) Penetrating eye injury (0.08) Corneal abrasion (0.73)
Condition
Giant cell arteritis (0.32) Herpes simplex keratitis (P = 0.001) Acute closed angle glaucoma (0.06) Papilloedema (P = 0.005) Retinal detachment (P = 0.024) Central retinal artery occlusion (P = 0.004) Retinal vein occlusion (P < 0.0001) 0
2
4
6
8
10
Self-rated ability to diagnose (scale 0–10)
Figure 2. Median self-rated ability to perform ophthalmic clinical skills of respondents of exposure with only non-clinical exposure (lectures and small-group tutorials) compared with those with exposure in clinical settings.
Respondents without clinical exposure (n = 208) Respondents with clinical exposure (n = 84) Visual acuity testing (0.06) Pupillary light reflex assessment (0.56) Visual fields (0.46) Extraocular muscle motility assessment (0.14)
Clinical skill
Pupillary dilatation (0.48) Appropriate ophthalmology referral (P = 0.008) Staining and examining the cornea with fluorescein (P = 0.012) Fundoscopy (P = 0.001) Complete ocular history (P = 0.001) Slit-lamp examination (P = 0.033) Intraocular pressure measurement (P = 0.013) Anterior chamber depth assessment (P = 0.021) 0
P < 0.0001), ophthalmology research (75% vs. 37.5%, P = 0.013), operating theatre exposure (47.4% vs. 35.6%, P = 0.045) or small-group tutorials (43.3% vs. 32.4%, P = 0.04). Two hundred and ninety-two respondents completed the self-evaluation of ability to diagnose and perform clinical skills. Median self-rated ability of respondents with clinical exposure outside lectures and small-group tutorials was higher for diagnosis of all conditions and for most specific ophthalmic clinical skills (Figs 1,2).
2 4 6 8 Self-rated ability to perform (scale 0–10)
10
All individual clinical skills were deemed important by over 90% of the 292 respondents who completed the self-evaluation, except for anterior chamber depth (53% deemed important), intraocular pressure measurement (63%) and slit-lamp examination (83%). The vast majority of respondents (92%) indicated that learning in ophthalmology was important for internship; however, only 38.5% of these reported learning enough ophthalmology to prepare for being a junior doctor despite established university ophthalmology curricula4
© 2014 Royal Australian and New Zealand College of Ophthalmologists
bs_bs_banner
904
Letters to the Editor
compared with another study that found that 64% of Australian junior doctors felt well prepared for internship. Fifty-five per cent of the respondents felt unprepared for emergency medicine, and 21% felt unprepared for intensive care rotations.5 These findings are supported by anecdotal reports from the Australian Medical Education Study, in which focus groups including junior doctors and senior medical students frequently reported not learning enough surgical subspecialties, particularly ophthalmology.6 Results of this study suggest that existing educational programmes should be evaluated with a view of optimizing teaching outcomes while working within existing time constraints, which are unlikely to change. Importantly, teaching opportunities through clinical rotations were identified as a more effective learning experience and produced greater confidence in ophthalmic examination and diagnosis. Recent many medical school curricula have moved to a problems-based learning approach. This teaching method improves students’ learning and retention7; however, the learning model focuses on a core curriculum of common or serious diseases and has reduced the time available for teaching subspecialties, including ophthalmology.8 To work within this paradigm, incorporation of problems-based learning into ophthalmology teaching should be encouraged, particularly for core parts of the curricula, for example the evaluation of sight-threatening conditions. A similar concept to problems-based learning is computer-based learning, utilizing problems-based modules online. Although it cannot replace clinical experience, studies have been favourable and it may be useful in optimizing students’ clinical learning of ophthalmology,9 without limitations of available human resources and time constraints. Limitations to this study include a possible selection bias with the response rate (25.3%) and voluntary nature of the survey, and subjective bias due to candidates varying ability to accurately self-evaluate. It is also possible that respondents inaccurately answered questions based on knowledge or skills learnt, following graduation from medical school. Ophthalmology education is an important part of medical school, and junior doctors are commonly required to evaluate ophthalmic conditions. Australian medical graduates have variable ophthalmology education and overall are not confident in approaching ophthalmic conditions or performing specific examinations. Broader teaching experiences should be encouraged and clinical ophthalmology rotations were identified as important by junior medical officers to improve their ophthalmic examination and diagnostic skills.
ACKNOWLEDGEMENTS We would like to acknowledge the Tasmanian Branch of the Royal Australian and New Zealand College of Ophthalmologists for providing a grant to enable completion of this study.
Allister R Howie,1,2 Robin G Abell MBBS,2 Erica Darian-Smith,1,2 Penelope L Allen PhD,2 Paul J McCartney FRANZCO3 and Brendan J Vote FRANZCO2 1 Launceston Clinical School, University of Tasmania, 2 Tasmanian Eye Institute, Launceston, and 3Hobart Eye Surgeons, Royal Hobart Hospital, Hobart, Tasmania, Australia Received 1 March 2014; accepted 8 March 2014.
REFERENCES 1. Vernon SA. Eye care and the medical student: where should emphasis be placed in undergraduate ophthalmology? J R Soc Med 1988; 81: 335–7. 2. Kumar NL, Black D, McClellan K. Daytime presentations to a metropolitan ophthalmic emergency department. Clin Experiment Ophthalmol 2005; 33: 586–92. 3. Stark D, Beinssen A, Morrey C. Ophthalmology in the undergraduate curriculum. A review in Queensland. Aust N Z J Ophthalmol 1992; 20: 297–303. 4. Fan JC, Sherwin T, McGhee CN. Teaching of ophthalmology in undergraduate curricula: a survey of Australasian and Asian medical schools. Clin Experiment Ophthalmol 2007; 35: 310–7. 5. Dent A, Crotty B, Cuddihy H et al. Learning opportunities for Australian prevocational hospital doctors: exposure, perceived quality and desired methods of learning. Med J Aust 2006; 184: 436–40. 6. Lawson M, Bearman M. Australian Medical Education Study Summary Report: Surveys, Focus Groups and Interviews. Melbourne, Vic: Department of Education, Science and Training, 2007. 7. Farrell TA, Albanese MA, Pomrehn PR Jr. Problembased learning in ophthalmology: a pilot program for curricular renewal. Arch Ophthalmol 1999; 117: 1223–6. 8. Williams G, Lau A. Reform of undergraduate medical teaching in the United Kingdom: a triumph of evangelism over common sense. Br Med J 2004; 329: 92–4. 9. Kuchenbecker J, Parasta AM, Dick HB. Internet-based teaching and learning in ophthalmology. Ophthalmologe 2001; 98: 980–4.
Ophthalmologists and cost uncertainty In many parts of regional Australia, ophthalmology services are provided on a visiting basis. Conceptually this is a great thing. It is highly commendable that Australian ophthalmologists get out of the comfort and convenience of their city-based practice to travel to “the bush” on a regular basis. For people who live in the country this is also a great thing. They can get world standard eye care and attention Competing/conflicts of interest: No stated conflict of interest. Funding sources: No stated funding sources.
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Copyright of Clinical & Experimental Ophthalmology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
