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Purpose To provide a current overview of the movement for open access to the peer review literature. Design Perspective. Methods Literature review of recent advances in the open access movement with a personal viewpoint of the nuances of the movement. Results The open access movement is complex, with many different constituents. The idealists for the open access movement are seeking open access to the literature but also to the data that constitute the research within the manuscript. The business model of the traditional subscription journal is being scrutinized in relation to the surge in the number of open access journals. Within this environment authors should beware predatory practices. More government and funding agencies are mandating open access to their funded research. This open access movement will continue to be disruptive until a business model ensures continuity of the scientific record. A flood of open access articles that might enrich, but also might pollute or confuse, the medical literature has altered the filtering mechanism provided by the traditional peer review system. At some point there may be a shake-out, with some literature being lost in cyberspace. Conclusions The open access movement is maturing and must be embraced in some format. The challenge is to establish a sustainable financial business model that will permit the use of digital technology but yet not endanger the decades-old traditional publication model and peer review system. Authors seem to be slower in adopting open access than the idealists in the movement.

The American Ophthalmological Society (AOS) is 1 of the 3 founding organizations of the American Board of Ophthalmology (ABO), in addition to the Section on Ophthalmology of the American Medical Association and the American Academy of Ophthalmology and Otolaryngology. The early history of the AOS and its role in the founding of the ABO are addressed in this article.

Both varicella and herpes zoster (HZ) can cause severe disease in certain age groups. The cell-mediated immune (CMI) response to the varicella zoster virus (VZV) is critical in preventing a recurrence of VZV. The varicella vaccine has markedly decreased the morbidity and mortality associated with varicella, but concerns linger about the cost and frequency of vaccine administration and the long-term effects on both adult varicella and HZ epidemiology in the individual and in the population. Therapy for HZ with an antiviral is only partially effective. A zoster vaccine is now available that boosts the CMI immune reaction to VZV in individuals and has proven safe and partially effective in preventing both HZ and post-herpetic neuralgia. Concerns about the zoster vaccine include the costs of administration, the overall health-care costs to society, and the acceptance and implementation of the vaccine in the elderly. Because of altered immune responses to VZV as a result of universal varicella vaccination it becomes even more compelling in the future to have a zoster vaccine ready to boost the CMI response to a sufficient level to prevent HZ. The 2 vaccines are intertwined in the future epidemiology of VZV disease.

Recent prospective studies from Europe suggest the use of intracameral antibiotics for prophylaxis of endophthalmitis, although the studies did not make a comparison with the most common United States prophylaxis techniques. Thus, the European studies as well as the present literature were reviewed in an attempt to place the European studies in perspective with regard to the present U.S. protocol and the available literature. There is no worldwide-established approach to prophylaxis of endophthalmitis. In the absence of a strong evidence-based approach most surgeons use surrogate studies to support their techniques and mold their opinions based on their interpretation of the literature and when they believe organisms causing endophthalmitis enter the eye. The review showed that preoperative topical antibiotics limit the number of bacteria on the ocular surface at surgery and postoperative topical antibiotics are most appropriate to address postoperative inoculation until the wound is sealed (with no tapering). Whereas intracameral antibiotic injection may be an appropriate route of administration to address inoculation occurring at the time of surgery, more research on safety and effectiveness is needed before we expose the millions of eyes having cataract surgery each year. A multipronged approach to limit endophthalmitis risk is also needed, with antibiotics as only part of the strategy.

Topic The incidence and morbidity of herpes zoster (HZ) and HZ ophthalmicus (HZO), and the potential impact of varicella vaccine on their epidemiology. Clinical Relevance Herpes zoster affects 20% to 30% of the population at some point in their lifetime; approximately 10% to 20% of these individuals will have HZO. Methods The peer-reviewed literature published from 1865 to the present was reviewed. Results Herpes zoster is the second clinical manifestation of varicella-zoster virus (VZV). The incidence and severity of HZ increase with advancing age. Varicella-zoster virus–specific cell-mediated immunity, which keeps latent VZV in check and is boosted by periodic reexposure to VZV, is an important mechanism in preventing VZV reactivation as zoster. Thus, widespread varicella vaccination may change the epidemiology of HZ. Herpes zoster ophthalmicus occurs when HZ presents in the ophthalmic division of the fifth cranial nerve. Ocular involvement occurs in approximately 50% of HZ patients without the use of antiviral therapy. There is a long list of complications from HZ, including those that involve the optic nerve and retina in HZO, but the most frequent and debilitating complication of HZ regardless of dermatomal distribution is postherpetic neuralgia (PHN), a neuropathic pain syndrome that persists or develops after the zoster rash has resolved. The main risk factor for PHN is advancing age; other risk factors include severe acute zoster pain and rash, a painful prodrome, and ocular involvement. Many cases of HZ, HZO, and PHN can be prevented with the zoster vaccine. Conclusion Vaccination is key to preventing HZ, HZO, and PHN, but strategies for both varicella and HZ vaccines will need to be evaluated and adjusted periodically as changes in the epidemiology of these VZV diseases become more evident.

Purpose of review The virology, pathophysiology, and treatment of the varicella zoster virus (VZV) have been investigated for many years now. Infection with VZV has different ramifications for people of different ages and immune status. The various aspects of VZV disease make it difficult to treat. Selected aspects of VZV disease that pertain to ocular disease are presented. Recent findings The risk factors for VZV disease in the different age spectrums and with concomitant immunodeficiencies have been further clarified. Studies suggest that the VZV may persist for prolonged periods on the cornea after herpes zoster ophthalmicus (HZO). Herpes Simplex Virus (HSV) or VZV may cause many cases of idiopathic uveitis with sectoral iris atrophy. The different patterns of retinal disease caused by VZV may relate to the immune status. Systemic antiviral medications for herpes zoster should be instituted within 72 hours of the rash but could be used later. Systemic antivirals combined with systemic corticosteroids improve the early quality of life in HZ patients. Postherpetic neuralgia is not prevented by early systemic antivirals or corticosteroids. Present systemic antivirals are all effective, but Famvir offers the best dosing schedule. The VZV vaccine is effective but there are some issues that suggest the need for a different vaccination regimen. Summary Further research must be performed on the clinical and therapeutic aspects of the VZV disease. Although both the vaccine and systemic antivirals have brought tremendous improvements, the disease persists. Therapy lessens but does not eliminate many of the complications. The disease may manifest in unpredictable patterns in this era of vaccination.

The primary testimony to a research study that involves patient volunteers and consumes public or private resources is publication in the peer-reviewed literature. Although a scientific article should be judged on it is own merits, subjectivity in study design by commercial entities, financial incentives for favorable interpretation by researchers, and other forms of bias by authors or peer reviewers may influence the final published work. The peer-reviewed literature rightfully has a powerful effect on decisions concerning both guidelines and funding of patient care, so journals strive to make their content valid and objective. Although it is widely agreed that “industry” involvement in ophthalmic research is necessary and desirable, it has been less enthusiastically but decidedly determined that full disclosure by all involved parties presently is the acceptable vehicle that permits the transference of study results into the peer-reviewed literature. Editors and readers recognize that several nonfinancial forms of bias, such as professional, intellectual, academic competition, or subtle prejudices based on personal experience can affect a study or peer review, but these will not be discussed further here. Only financial disclosure has emerged as an attainable goal over the past few decades, but the process has not been perfected either in concept or practice. The topic of financial conflicts remains contentious in medicine, with some finding the requested reporting burdensome and others still unsatisfied that disclosure is often translucent, at best. Some major journals still do not require financial disclosure, some do not define their disclosure policy, some disagree with commonly used definitions and terms, some do not request the disclosure until after an article has passed the peer review process, and nearly every journal has a different way of conveying or not conveying information about financial relationships to the reader. There is evidence, however, that readers are mindful of disclosure information and make judgments about an article’s quality based on it, having a preference for government-funded research compared with studies supported by industry. The New England Journal of Medicine and the Journal of the American Medical Association have led this movement in financial disclosure, catalyzed by embarrassing situations involving failure of forthright communication by their authors. As reviewed by Blum et al, there has been a concerted effort to protect the integrity and public trust in the peerreviewed literature by the Institute of Medicine, the International Committee of Medical Journal Editors (ICMJE), the World Association ofMedical Editors, the Council of Science Editors, the Committee on Publication Ethics, and others, each of which has drafted guidelines on disclosure as a means for improving transparency. A uniform ICMJE author disclosure form was suggested and then developed by the major international journals several years ago, and has now undergone a number of iterations following suggestions by

Despite the high frequency of cataract surgery, there are still no definitive studies on antibiotic prophylaxis against endophthalmitis after cataract surgery. Most surgeons follow an empiric approach. The results of several recent studies shed additional light on this complex topic. There is better knowledge of the usual source of the infection and the specific organisms incriminated. This review presents some principles of prophylactic treatment and selected literature that addresses the effectiveness of antisepsis, topical preoperative antibiotics, intracameral antibiotics, subconjunctival antibiotics, systemic antibiotics, and postoperative antibiotics. The worldwide problem of antibiotic resistance should temper our approach. Some organizational statements are reviewed, and personal recommendations are offered. Controversy still abounds.

To review the changing epidemiology of herpes simplex disease and correlate it with the epidemiology of ocular herpes simplex disease.A review of pertinent reports in the world literature about the epidemiology of herpes simplex and specifically about ocular herpes simplex.In developed countries, many individuals are reaching adolescence and adulthood without prior herpesvirus infection. Herpes simplex genital infection is increasing at a rapid rate in sexually active adolescents and adults, with about one in six adults now infected in the United States. Similar statistics are confirmatory worldwide in developed countries. Active herpes simplex infection is a risk factor for acquisition of human immunodeficiency virus. The Herpetic Eye Disease Study, as well as prior studies from Moorfields Eye Hospital and the Mayo Clinic in Rochester, Minnesota, provides us with the epidemiology of ocular herpes simplex. Recent studies suggest an older age of onset and perhaps overall more severe ocular disease as compared with the older literature.Herpes simplex is a significant health concern at present with genital infections increasing in epidemic proportions. This is also reflected in a rise in the incidence of neonatal herpes. Herpes simplex virus type 1 (HSV-1) infection is being acquired for the first time in an older age group. A significant and increasing proportion of genital herpes is caused by HSV-1. Serologic studies are no longer as useful in distinguishing orofacial herpes from genital herpes. More acute retinal necrosis syndrome cases are associated with HSV-2. Speculation about the future of ocular herpes is made based on this changing epidemiology.

Purpose To review the rationale for various methods of perioperative prophylaxis in elective cataract surgery. Methods The surgical and ophthalmologic literature is reviewed to determine accepted principles for the use of perioperative prophylactic agents in clean elective surgical procedures. Results After an assessment of the nonophthalmic surgical literature, specific principles are applied to the use of antimicrobial agents in perioperative prophylaxis of cataract surgery. Current practice patterns and specific techniques of perioperative prophylaxis are scrutinized. The emerging problem of antimicrobial resistance in the world and specifically in ophthalmology is addressed. Recommendations are offered balancing the needs of the individual patient with the best interests of society as a whole. Conclusion Potent therapeutic agents should be reserved for therapy. A method of perioperative prophylaxis is suggested, with a stratified approach indicated in selected circumstances. A clear consensus is probably not possible with divergent views expressed.

Objective To evaluate the mydriatic effect of tropicamide eyedrops as a diagnostic test for Alzheimer's disease. Material and Methods In a double-blind, placebo-controlled study, we assessed pupillary responses in 22 normal control subjects, 23 patients with probable Alzheimer's disease, 4 patients with isolated memory difficulty, and 6 patients with nonAlzheimer's dementia. Three separate studies were performed, the second and third on a subset of the original group. With use of infrared binocular pupillography, after 5 minutes of dark adaptation, we averaged pupil size during a 1-minute interval for baseline determinations. We then instilled 0.01 % tropicamide into one eye. In the first two studies, we averaged pupil size for a 1-minute period at 5-minute intervals for 30 minutes, followed by a pupil light reflex test. In the third study, we measured pupil size every 5 minutes for 45 minutes and omitted the light reflex test. Results No significant difference was noted in pupil dilatation between normal subjects and patients with Alzheimer's disease and between patients with non-Alzheimer's dementias and the Alzheimer's disease group in all three studies. Furthermore, on reperformance of the test in the same patients, more than 50% changed from a group above or below 13% pupil dilatation (a cutoff reported to distinguish Alzheimer's disease from normal control subjects) to the opposite group. Conclusion Results of this study indicate that pupil measurement after instillation of tropicamide cannot be used as a reliable diagnostic test for Alzheimer's disease. Moreover, test-retest reliability with use of dilute tropicamide eyedrops is questionable.

Important concepts about glaucoma have evolved during the past few decades. Glaucoma is a family of diseases not defined by a specific intraocular pressure but rather as an optic neuropathy that can occur at any intraocular pressure depending on the optic nerve susceptibility of the individual person. Increased risk factors for idiopathic open-angle glaucoma include advancing age, black race, a family history of glaucoma, and increased intraocular pressure. The primary-care physician is in the prominent position of recognizing patients with increased risk factors or suspicious eye findings who should be referred to an ophthalmologist. Topically applied ophthalmic medications have systemic side effects that must be recognized and monitored by the primary-care physician. In the United States, glaucoma is usually treated with topically applied medications; laser or surgical therapy is done if medical treatment fails. The National Eye Institute is conducting multicenter studies to confirm whether this is still the most appropriate strategy for this common disease.

Background: The Ophthalmic Knowledge Assessment Program (OKAP) Task Force of the American Academy of Ophthalmology has reviewed the present OKAP examination and addressed the goals of this resident-in-training examination. Simultaneously, the American Board of Ophthalmology has been assessing its Written Qualifying Examination (WQE) as a certifying tool. Method: The history of the OKAP examination is chronicled along with a discussion of the goals of this examination as a stimulus for resident education. Conclusion: The new OKAP examination is structured specifically for residents-intraining and is now administered separately from the WQE. The OKAP examination is moving in the direction of a criterion referenced examination based on a defined content outline. Twelve subtest areas are tested. Future goals are to improve subtest reliability and increase feedback to residents and program directors.

The statement and recommendations in this report resulted from detailed discussions between geriatricians and specialists of 10 medical and surgical disciplines, including representatives of the American Academy of Physical Medicine and Rehabilitation. These physicians and their parent organizations are participants in a major project supported by the John A. Hartford Foundation and the American Geriatrics Society. The goal of this project is to improve the care of older patients. This position statement reviews demographic forces shaping contemporary health care, states the objectives of project, and lists 10 specific recommendations. The recommendations encompass attitudes, knowledge, medical training, clinical service delivery, and advocacy.

Ocular adnexal lymphoproliferative lesions consist of a spectrum of disease entities, including reactive lymphoid hyperplasia, atypical lymphoid hyperplasia, and lymphoma. No clinical or radiologic criteria facilitate a distinction among these lymphoproliferative lesions. The two hyperplastic processes may evolve to localized or systemic lymphoma. A similar pattern is evident in other mucosa-associated lymphoid tumors elsewhere in the body. Most ocular adnexal lymphomas are small lymphocytic non-Hodgkin's tumors with an indolent course; frequently, they remain localized to the ocular adnexa. In comparison, intermediate- and high-grade lymphomas are less common in the ocular adnexa but more aggressive. An approach to the diagnosis and treatment of these complex entities is suggested. Despite new pathologic classification schemes, immunophenotypic labeling, and molecular genetic analysis, the prognosis for patients with small-cell lymphoma in the ocular adnexa is difficult to predict.

words, no more and no less, makes writing “vigorous.” 1 This editorial’s theme might be summarized by a spin-off admonition: omit heedless words. Specifically, we wish to highlight the problem of plagiarism for our readers and to advise authors to heed contemporary expectations for their published work. Plagiarism,accordingtoHexham,is,“thedeliberate attempt to deceive the reader through the appropriation and representation as one’s own, the work and word of others.” 2 When discovered, it can lead to adverse consequences for the author and damage to a journal’s reputation, whose influence and usefulness depend on trust: “the trust of readers, authors, researchers, editors, patients, research subjects, funding agencies and administrators of public health policy.” 3 In this electronic age, the precise definition, limits, and significance of plagiarism have been in the spotlight. We believe that plagiarism is serious professional misconduct. To understand the contrasting and changing attitudes about plagiarism, a review of its history is helpful. Society’s stance toward plagiarism reflects its views and values of individuality, originality, and intellectual property. For most of the 5000 years written language has been in use, plagiarism as a concept has not existed. In the “golden age” of Greece, repetition without attributiondwhat we would now consider plagiarismdwas encouraged and valued. The views of Hippocrates and Galen were repeated or paraphrased unchallenged for 15 centuries, as were the teachings of Aristotle. 4 When a rival poet stole his verses in the first

The word “herpes” derives from the Greek verb meaning “to creep or crawl” and was used to describe spreading cutaneous lesions in the writings of Hippocrates some 25 centuries ago. There are now eight recognized human herpes viruses: herpes simplex virus type 1 (HSV-1), HSV-2, varicella-zoster virus (VZV), cytomegalovirus, Epstein-Barr virus, human herpes virus 6 (associated with roseola infantum), human herpes virus 7 (associated with roseola infantum and febrile convulsions), and human herpes virus 8 (associated with Kaposi sarcoma and lymphomas).

Varicella-zoster virus causes two distinct syndromes. Primary infection presents as varicella (or chickenpox), a contagious and usually benign childhood illness that occurs in epidemics among susceptible children. The reactivation of the virus, usually associated with decline in cell-mediated immunity, occurs as herpes zoster (HZ) (shingles). Varicella is spread through droplet infection with an initial viremia, and subsequent viral spread to the skin and the eye. It is easily disseminated to susceptible individuals. Ninety-five percent of the population has serological evidence of prior VZV infection with or without symptomatic varicella. The incidence of varicella has diminished 70% after implementation of the varicella vaccine in 1995.

Lawrence first described Fuchs’ uveitis syndrome (FUS) in 1843. In 1906, in a series of 38 patients, Ernst Fuchs’ described a condition called complicated heterochromia, which was characterized by heterochromia, inflammation, and cataract. This disorder has also been called Fuchs’ heterochromic uveitis and Fuchs’ heterochromic cyclitis. However, vitreous opacities and chorioretinal scars are common, and therefore the frequently used term cyclitis is not entirely accurate.

Medical journals hold an exalted position in medicine, but have many shortcomings. This perspective reviews some of the shortcomings of medical journals which are primarily related to inexperience, bias, and commercialism. The issues discussed include the uncertain mission of the traditional medical journal in the modern digital age, the inherent inexperience of voluntary editorial boards, the weaknesses and capricious nature of decisions made by the peer-review process, the uneven value of most journal articles, the bias in what gets submitted and published in journals, the misunderstanding about the criteria for authorship, the misunderstanding of the need for ethical review board approval of studies, the misunderstanding of the need for informed consent for research from patients and ethical review boards, the various sources of assistance to editors and authors in dealing with the many ethical issues arising in the publication process, the commercialization and manipulation of medical journals by industry, the prevalent and complex financial entanglements of authors with industry, and the imperfect impact factor, which has the potential to be abused. The perspective concludes with theorization of the role of medical journals in the future. Readers need to scrutinize data in the literature carefully and interpret the discussions and conclusions critically, as there are biases in what is published in medical journals.

Studies in the basic and clinical sciences have yielded new information about the biology, infection, latency, and recurrence of the varicella-zoster virus. Contrast is made with the herpes simplex virus. The host-viral relationship is an extremely dynamic one with clinical disease being determined primarily by the host cellular immune system. The complications of herpes zoster ophthalmicus are related to multiple mechanisms including viral growth, vascular and neural damage, and the host-immune response to infection. There are several laboratory tests available for confirming the diagnosis or determining the immune status. Systemic acyclovir administered early in the course alleviates many of the symptoms of herpes zoster ophthalmicus. Acute and postherpetic neuralgia remain significant and enigmatic problems; an update of therapeutic options is offered. The role of corticosteroids in herpes zoster ophthalmicus is scrutinized along with the potential and uncertainties of a varicella-zoster virus vaccine.

A recent epidemiologic study of ocular herpes simplex in 151 patients over a 33 year old period in Rochester, Minnesota has challenged some of the clinical and epidemiologic tenets about the disease. The incidence rate for new and recurrent cases and the prevalence rate was calculated and projected to the white U.S. population. The recurrence rate assessed by life table methods were determined for up to 20 years after the first episode and these rates rose following repeated episodes. Previous studies in the same community allow comparison of the incidence rates with other herpetic diseases. This community based study more accurately defines many of the features of the disease such as the prevalence among the sexes, the increasing age at presentation, the frequency of bilateral disease, the relationship of the initial disease to the future recurrence patterns, the frequency of lid, epithelial, stromal, and uveitis in an unselected community population, and the final visual outcome. This data estimates more accurately the morbidity and social impact of the condition.

The corneal endothelium is affected by age, disease, and intraocular surgery. With age, the endothelial cell density decreases linearly, the hexagonal pattern is less common, and there is an increased variation in cell size and shape. There are primary and secondary endotheliopathies in elderly patients which further compromise the endothelial reserve. Intraocular surgery causes cell loss in the superior cornea which requires a transformation and migration of endothelial cells from the central and inferior cornea. Although a stable endothelial mosaic is reestablished in most corneas, some maintain a bizarre endothelial appearance which is correlated with continued cell loss. Intraocular surgery causes an acute cell loss as well as a chronic cell loss which is greater than the normal attrition due to aging. There are many variables in predicting future corneal edema; longitudinal observation of endothelial cell loss may be the best prognosticator. [Refractive and Corneal Surgery 1991;7:81-86.]

PURPOSE: To report three cases in which herpes simplex keratitis developed after initiation of latanoprost therapy. METHODS: Case report. RESULTS: One patient with a history of herpes simplex keratitis had recurrence of herpes simplex keratitis with latanoprost treatment, resolution when latanoprost was stopped, and another recurrence when rechallenged with latanoprost. A second patient with a history of herpes simplex keratitis had bilateral recurrence with initiation of latanoprost; antiviral therapy could not eradicate herpes simplex keratitis until the latanoprost was discontinued. The third patient with latanoprost-associated herpes simplex keratitis cleared with the discontinuation of latanoprost and start of antiviral therapy; reinstitution of latanoprost with prophylactic antiviral medication kept the cornea clear, but as soon as the antiviral suppression was discontinued, herpes simplex keratitis reappeared. CONCLUSION: Latanoprost, among its diverse pharmacologic effects, may mediate inflammation in the eye. Prostaglandins may be a final common pathway for stimulating recurrence of herpes simplex keratitis. Clinicians should be aware of this possible association.

Immanuel Kant stated, "Everything has either a price, or it possesses dignity." 1(p53) Downie further elaborated that professionals should be "independent of the state or commerce." 2 Medicine is the prototype profession, incorporating a specific body of knowledge; a demonstrated competence in defining problems and solutions; a commitment to self-improvement, self-monitoring, and self-regulation; a system of admission and monitoring new members; and an ethical responsibility to use the unique knowledge and competence for the best interests of patients (ie, to resolve conflicts of interest in our patients' favor). 3 In recognition of certain conduct, society confers professional status to physicians, but this privilege must be repeatedly earned for the status to be preserved. In this article, I delineate the specific challenges peer-reviewed medical journals face in this age of commercialism within the medical profession.