Keratoconus disease classification with multimodel fusion and vision transformer: a pretrained model approach

OBJECTIVE

Our objective is to develop a novel keratoconus image classification system that leverages multiple pretrained models and a transformer architecture to achieve state-of-the-art performance in detecting keratoconus.

METHODS AND ANALYSIS

Three pretrained models were used to extract features from the input images. These models have been trained on large datasets and have demonstrated strong performance in various computer vision tasks.The extracted features from the three pretrained models were fused using a feature fusion technique. This fusion aimed to combine the strengths of each model and capture a more comprehensive representation of the input images. The fused features were then used as input to a vision transformer, a powerful architecture that has shown excellent performance in image classification tasks. The vision transformer learnt to classify the input images as either indicative of keratoconus or not.The proposed method was applied to the Shahroud Cohort Eye collection and keratoconus detection dataset. The performance of the model was evaluated using standard evaluation metrics such as accuracy, precision, recall and F1 score.

RESULTS

The research results demonstrated that the proposed model achieved higher accuracy compared with using each model individually.

CONCLUSION

The findings of this study suggest that the proposed approach can significantly improve the accuracy of image classification models for keratoconus detection. This approach can serve as an effective decision support system alongside physicians, aiding in the diagnosis of keratoconus and potentially reducing the need for invasive procedures such as corneal transplantation in severe cases.

Prevalence and associated factors of corneal opacity among adults in Kolladiba town, Northwest Ethiopia: a cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence and associated factors of corneal opacity among adults in Kolladiba town, Northwest Ethiopia.

METHODS AND ANALYSIS

A community-based cross-sectional study was conducted using a systematic random sampling technique. A total of 846 adult individuals were recruited for the study. Ethical approval was obtained from the University of Gondar School of Medicine Ethical Review Committee. A standardised, semistructured questionnaire plus an ocular examination were used to collect the data. The data were entered into Epi Info V.7 and cleaned and analysed using SPSS V.26. Binary and multivariable logistic regression analyses were performed to select candidate variables and identify statistically significant factors. Variables with a p value of less than 0.05 according to the multivariable logistic regression analysis were considered to be statistically significant.

RESULTS AND CONCLUSION

The prevalence of corneal opacity among the study participants was 27.2% (95% CI 24.4% to 30.4%). In this study, age 49-60 years (adjusted OR (AOR): 1.90; 95% CI 1.03 to 3.32), age ≥61 years (AOR=2.12; 95% CI 1.17 to 3.87), inability to read and write (AOR=2.65; 95% CI 1.68 to 4.16), middle-income level (AOR=2.12; 95% CI 1.30 to 3.47) and poor income level (AOR=4.96; 95% CI 3.04 to 8.09) were factors that were significantly associated with corneal opacity.In this study, the prevalence of corneal opacity was considerably high. Being poor and unable to read and write were the primary factors significantly associated with corneal opacity. Hence, concerned stakeholders should strive to reverse the effects of corneal opacity on the quality of life of the study and causal studies should be considered in the future.

Acute spontaneous vortex vein occlusion: clinical features, multimodal imaging and natural course

AIMS

To describe the clinical features, multimodal imaging, treatments and natural course of acute spontaneous vortex vein occlusion.

METHODS

Clinical data were collected on nine patients with acute vortex vein occlusion. The symptoms and signs, multimodal imaging, treatments and follow-up results were summarised.

RESULTS

Six patients (66.7%) were men and three (33.3%) were women. The mean age was 47.8±15.4 years. Patients were initially misdiagnosed as having choroidal tumour (66.7%), scleritis (22.2%) and peripheral exudative haemorrhagic chorioretinopathy (11.1%). The related clinical characteristics included choroidal pseudo-tumour (100%), anterior segment injection (88.9%), acute ocular pain (77.8%), transient blurred vision (66.7%) and subsequent scleral icterus (66.7%). Six patients (66.7%) experienced a definite Valsalva manoeuvre prior to the onset. In acute phase, ultrasonography showed a low-to-medium reflective lesion without inside blood flow signal (mean thickness, 2.7±0.6 mm). Swept-source optical coherence tomography angiography (SS-OCTA) demonstrated the dilated vortex veins and ampulla with suprachoroidal haemorrhage and exudation. Indocyanine green angiography (ICGA) demonstrated choroidal circulation abnormalities in the affected quadrant. MRI showed a well-defined mass with enhancement. The main treatment was medical observation (44.5%). The choroidal pseudo-tumour spontaneously resolved with a mean course of 4.1±1.9 weeks.

CONCLUSIONS

Acute vortex vein occlusion is a rare condition and initial misdiagnosis is not uncommon. It is mainly identified as an evanescent choroidal pseudo-tumour with acute pain, red eye and blurred vision. Widefield ICGA and SS-OCTA can offer valuable diagnostic clues. Medical observation may be a treatment option.

Real-world evaluation of smartphone-based artificial intelligence to screen for diabetic retinopathy in Dominica: a clinical validation study

OBJECTIVE

Several artificial intelligence (AI) systems for diabetic retinopathy screening have been validated but there is limited evidence on their performance in real-world settings. This study aimed to assess the performance of an AI software deployed within the diabetic retinopathy screening programme in Dominica.

METHODS AND ANALYSIS

We conducted a prospective, cross-sectional clinical validation study. Patients with diabetes aged 18 years and above attending the diabetic retinopathy screening in primary care facilities in Dominica from 5 June to 3 July 2021 were enrolled.Grading was done at the point of care by the field grader, followed by counselling and referral to the eye clinic. Images were then graded by an AI system. Sensitivity, specificity with 95% CIs and area under the curve (AUC) were calculated for comparing the AI to field grader as gold standard.

RESULTS

A total of 587 participants were screened. The AI had a sensitivity and specificity for detecting referable diabetic retinopathy of 77.5% and 91.5% compared with the grader, for all participants, including ungradable images. The AUC was 0.8455. Excluding 52 participants deemed ungradable by the grader, the AI had a sensitivity and specificity of 81.4% and 91.5%, with an AUC of 0.9648.

CONCLUSION

This study provides evidence that AI has the potential to be deployed to assist a diabetic screening programme in a middle-income real-world setting and perform with reasonable accuracy compared with a specialist grader.

Early use of intravitreal triamcinolone to inhibit traumatic proliferative vitreoretinopathy: a randomised clinical trial

AIMS

To evaluate the efficacy and safety of intravitreal triamcinolone acetonide (TA) injection at the end of emergency surgery for open globe injury (OGI) to suppress traumatic proliferative vitreoretinopathy (TPVR).

METHODS

A single-centre, participant-masked, prospective, randomised controlled clinical trial. A total of 68 globe rupture patients with zone III were randomised to the control group (n=34) or the TA group (n=34) in 1:1 allocation ratio. Patients were treated with 0.1 mL TA in the TA group and 0.1 mL balanced salt solution in the control group at the end of emergency surgery. The primary outcome was the assessment of TPVR during vitrectomy 10±3 days later. Secondary outcomes included visual acuity (VA), retinal attachment rate, macular attachment rate, proliferative vitreoretinopathy (PVR) recurrent rate, side effects 6 months after vitrectomy.

RESULTS

During vitrectomy, the TPVR grade of the control group was significantly more severe than the TA group (p=0.028). The TPVR score was significantly better in the TA group (9.30±0.82) than in the control group (6.44±1.06) (p=0.036). The final VA improved in 23 eyes (92%) in the TA group and in 14 eyes (63.64%) in the control group (p=0.008). The retinal attachment rates were 88% and 63.64% in the TA and control group, respectively (p=0.049). The two groups showed no significant difference in macular repositioning and PVR recurrent rate (p=0.215, 0.191). Temporary intraocular pressure elevation occurred in one eye in the TA group after emergency surgery.

CONCLUSIONS

Early intravitreal TA injection for OGI effectively reduces TPVR, increases surgical success and improves visual prognosis.

Real-world clinical and molecular management of 50 prospective patients with microphthalmia, anophthalmia and/or ocular coloboma

BACKGROUND/AIMS

Microphthalmia, anophthalmia and coloboma (MAC) are clinically and genetically heterogenous rare developmental eye conditions, which contribute to a significant proportion of childhood blindness worldwide. Clear understanding of MAC aetiology and comorbidities is essential to providing patients with appropriate care. However, current management is unstandardised and molecular diagnostic rates remain low, particularly in those with unilateral presentation. To further understanding of clinical and genetic management of patients with MAC, we charted their real-world experience to ascertain optimal management pathways and yield from molecular analysis.

METHODS

A prospective cohort study of consecutive patients with MAC referred to the ocular genetics service at Moorfields Eye Hospital between 2017-2020.

RESULTS

Clinical analysis of 50 MAC patients (15 microphthalmia; 2 anophthalmia; 11 coloboma; and 22 mixed) from 44 unrelated families found 44% had additional ocular features (complex) and 34% had systemic involvement, most frequently intellectual/developmental delay (8/17). Molecular analysis of 39 families using targeted gene panels, whole genome sequencing and microarray comparative genomic hybridisation identified genetic causes in, 28% including novel variants in six known MAC genes (SOX2, KMT2D, MAB21L2, ALDH1A3, BCOR and FOXE3), and a molecular diagnostic rate of 33% for both bilateral and unilateral cohorts. New phenotypic associations were found for FOXE3 (bilateral sensorineural hearing loss) and MAB21L2 (unilateral microphthalmia).

CONCLUSION

This study highlights the importance of thorough clinical and molecular phenotyping of MAC patients to provide appropriate multidisciplinary care. Routine genetic testing for both unilateral and bilateral cases in the clinic may increase diagnostic rates in the future, helping elucidate genotype-phenotype correlations and informing genetic counselling.

Heterozygous variants c.781G>A and c.1066dup of serine protease 56 cause familial nanophthalmos by impairing serine-type endopeptidase activity

BACKGROUND/AIMS

Nanophthalmos is a rare developmental, bilateral, sporadic or hereditary form of microphthalmos. In this study, the heterozygous variants c.781G>A and c.1066dup of the PRSS56 gene were identified in two patients with nanophthalmos. This study reports the clinical manifestation and the underlying pathogenic mechanism.

METHODS

Whole-exome sequencing was performed to identify the pathogenic genes in a Chinese family with nanophthalmos. The molecular simulation was used to predict the structures of wild-type or mutant PRSS56. The PRSS56 wild-type or mutation overexpression cellular models have been constructed accordingly. The subcellular localisation was then observed using immunofluorescence and Western-blot techniques. The Folin-Ciocalteu assay was carried out to evaluate serine-type endopeptidase activity, and a wound-healing assay was used to examine the cellular migratory ability.

RESULTS

The whole-exome sequencing revealed that heterozygous variants c.781G>A and c.1066dup of the PRSS56 gene might contribute to nanophthalmos. Both variants were not identified in the dbSNP, 1000 Genome project or ESP6500 databases. Furthermore, the variants were highly conserved and were involved in biological functions. The mutations result in destructive protein structure and impede serine-type endopeptidase activity, thereby impairing subcellular localisation and cellular migration.

CONCLUSION

The c.781G>A and c.1066dup variants of the PRSS56 gene might negatively affect protein structures, subcellular localisation, serine-type endopeptidase activity and cellular migratory ability. Together, these changes could lead to the development of nanophthalmos. This study identifies the PRSS56 gene as a potential target for nanophthalmos diagnosis and treatment.

Ki67 is a better marker than PRAME in risk stratification of BAP1-positive and BAP1-loss uveal melanomas

BACKGROUND

Accurate risk stratification of uveal melanoma (UM) patients is important for determining the interval and frequency of surveillance. Loss of BAP1 expression has been shown to be strongly associated with UM-related death and metastasis.

METHODS

In this study of 164 enucleated UMs, we assessed the prognostic role of preferentially expressed antigen in melanoma (PRAME) expression and Ki67 proliferation index measured by digital quantitation using QuPath programme in patients with BAP1-positive and BAP1-loss UMs.

RESULTS

In univariate analyses with log-rank tests and Kaplan-Meier curves, PRAME further stratified only overall survival (OS) in BAP1-positive and BAP1-loss tumour groups. However, Ki67 further stratified both OS and disease-free survival (DFS) in BAP1-positive and BAP1-loss tumour groups. In multivariate analyses, Ki67 percentage and BAP1 were independent survival predictors for both OS and DFS, whereas PRAME was not a significant covariate. In model comparisons, combined Ki67 and BAP1 performed better than combined PRAME and BAP1 in risk-stratifying patients for both OS and DFS. Ki67 was better than PRAME in risk stratification of BAP1-positive UMs. Low Ki67 index correlated with significantly prolonged DFS in BAP1-loss UMs.

CONCLUSION

A panel of Ki67 and BAP1 could be a helpful risk stratification strategy for UM.

Bibliometric analysis of the uveitis literature and research trends over the past two decades

OBJECTIVE

This study aimed to examine the publication patterns and present a current view of the field of uveitis using a bibliometric analysis.

DESIGN

Bibliometric analysis.

METHODS AND ANALYSIS

A comprehensive search of three databases including MEDLINE, EMBASE and Cochrane was conducted from 1 January 2000 to 31 December 2022. Search results from all three databases were subjected to analysis by Bibliometrix, an R programme that analyses large literature dataset with statistical and mathematical models. Visualisation of collaboration networks and relevance between countries was presented with VOSviewer.

RESULTS

A total of 26 296 articles were included in the analysis. The field of uveitis has undergone a significant exponential growth since 2000, with an average growth rate of 4.14%. The most substantial annual growth was between the years 2021 and 2022 (36%). According to the corresponding author's countries, the three most productive countries were Turkey (3288, 12.6%), the USA (3136, 12%) and Japan (1981, 7.6%). The USA (243, 31.4%), England (117, 15%) and Germany (62, 8%) are the top three countries that contributed to clinical trials. The average international collaboration of all countries was 2.5%.

CONCLUSIONS

Uveitis literature has undergone significant growth in the past two decades. The demographic factors of publishing countries lead to their various productivity and types of these uveitis studies, which is closely associated with the countries' scientific research resources and patient populations.

Comparative study of the effects of laser peripheral iridotomy and cataract surgery on anterior chamber angle parameters in primary angle closure suspect patients

INTRODUCTION

Prophylactic laser peripheral iridotomy (LPI) and cataract surgery are considered the primary treatments for primary angle closure suspect (PACS) as they have proven effectiveness in widening the iridocorneal angle and addressing the underlying anatomical issues associated with this condition. The objective of this study is to compare the impact of LPI and cataract surgery on anterior chamber angle parameters, aiming to fill the existing research gap.

METHODOLOGY

A prospective comparative study was conducted, involving 76 eyes of 61 patients. The study focused on patients diagnosed with PACSs and early cataract. The patients received treatment either through LPI or cataract surgery. Comprehensive eye examination was performed, including gonioscopy and anterior segment parameters were measured using anterior segment ocular coherence tomography (ASOCT). Follow-up examinations were conducted at 1 week and 1 month after the procedures, which included ASOCT and gonioscopy performed during the 1-month follow-up.

RESULTS

All anterior chamber angle parameters increased significantly after treatment in both groups, including trabecular iris angle (TIA), angle opening distance at 250, 500 and 750 µm (AOD 250, AOD500, AOD750), trabecular iris surface area at 500 and 750 µm (TISA500, TISA750) and angle recess area at 500 and 750 µm from scleral spur (ARA500, ARA750) (p<0.05 for all). Moreover, all these parameters were greater after cataract surgery than after LPI (p<0.05 for all).

CONCLUSION

Compared with LPI, cataract extraction resulted in a wider anterior chamber angle. Moreover, no residual angle closure was observed after cataract extraction, which could morphologically prevent the progress of angle closure. Thus, cataract extraction is superior to LPI in PACSs with early cataract in widening the anterior chamber angle.

Novel loci for ocular axial length identified through extreme-phenotype genome-wide association study in Chinese populations

PURPOSE

To investigate genetic loci associated with ocular axial length (AL) in the Chinese population.

METHODS

A genome-wide association study meta-analysis was conducted in totalling 2644 Chinese individuals from 3 cohorts: the Guangzhou cohort (GZ, 537 high myopes and 151 hyperopes), Wenzhou cohort (334 high myopes and 6 hyperopes) and Guangzhou Twin Eye Study (1051 participants with normally distributed AL). Functional mapping was performed to annotate the significant signals, possible tissues and cell types by integrating available multiomics data. Logistic regression models using AL-associated SNPs were constructed to predict three AL status in GZ.

RESULTS

Two novel loci (1q25.2 FAM163A and 7p22.2 SDK1) showed genome-wide significant associations with AL, together explaining 29.63% of AL variance in GZ. The two lead SNPs improved the prediction accuracy for AL status, especially for hyperopes. The frequencies of AL decreasing (less myopic) alleles of the two SNPs were lowest in East Asians as compared with other populations (rs17370084: f EAS=0.03, f EUR=0.24, f AFR=0.05; rs73046501: f EAS=0.06, f EUR=0.07, f AFR=0.20), which was in line with the global distribution of myopia. The cerebral cortex and gamma-aminobutyric acidergic interneurons showed possible functional involvement in myopia development, and the galactose metabolic pathways were significantly enriched.

CONCLUSION

Our study identified two population-specific novel loci for AL, expanding our understanding of the genetic basis of AL and providing evidence for a role of the nervous system and glucose metabolism in myopia pathogenesis.

Impact of the COVID-19-induced lockdown on the incidence of ocular trauma presenting to a tertiary care hospital

Objective

To assess the effects of lockdown and unlock phases mandated in view of COVID-19 on the incidence and characteristics of ocular trauma presenting to a tertiary care hospital.

Methods and Analysis

The study was carried out as a hospital record based retrospective comparative analysis on patients presenting with ocular trauma in the lockdown period (March-July 2020) compared with the same time frame of the previous year considered as prelockdown period (March-July 2019) and during the unlock phases (August-December 2020).

Results

Overall, the casualty department saw 464 patients of ocular trauma in the prelockdown period, 173 in the lockdown and 253 in unlock. The study showed a 44% reduction in patients visiting the casualty department for trauma during the lockdown compared with prelockdown, and a 62% reduction specifically in ocular trauma. The unlock phase showed a 21% reduction in ocular trauma compared with prelockdown and a 41% increase compared with the lockdown. In all three phases, the majority of people affected by ocular trauma were middle aged males from a rural background, sustained by assault. The lockdown saw a decrease in outdoor assaults (45%) and road traffic accidents (22%). Trauma sustained by females (18%) increased in the lockdown, as did home-based assaults (150%) and sexual assaults. The presentation of trauma, especially road traffic accidents and outdoor assaults saw a steady rise during the unlock.

Conclusion

The lockdown mandated by the government in response to the COVID-19 pandemic had a significant impact on the trends of trauma presenting to healthcare facilities. There was a decrease in the overall number of patients approaching the casualty during the lockdown. However, during the lockdown, there was an increase in home-based trauma as opposed to outdoor assaults being the primary cause of trauma prior to the lockdown.

Association between temperature changes and uveitis onset in mainland China

BACKGROUND

Some uveitis subtypes show seasonal patterns. Whether these patterns are caused by seasonally varying temperatures or by other climatic factors remains unknown. This ecological research aimed to quantify the association between climate variability and uveitis onset.

METHODS

We combined data from the largest database of uveitis cases with surface climate data to construct panel data. We used choropleth maps to visually assess spatial uveitis variations.

RESULTS

Among 12 721 reports of uveitis originating from 31 provinces of mainland China from 2006 to 2017, we found that a 1°C increase in monthly temperature was associated with a rise in approximately 2 uveitis reports per 1000 individuals (95% CI 0.00059 to 0.0029). This association was present across all provinces, ranging in effect size from 0.0011 to 0.072 (95% CI 0.00037 to 0.10). A clear 0-3 months of cumulative lagging effect was noted across all types of uveitis, with the strongest effect for non-infectious uveitis (0.0067, 95% CI 0.0041 to 0.013). Stratified by age and sex, we found that men and people aged 20-50 years were more affected by temperature variations. Our model predicts that China might experience an increase in uveitis cases due to future global warming.

CONCLUSION

Our study is the largest-ever investigation of the association between uveitis and climate and, for the first time, provides evidence that rising temperature can affect large-scale uveitis onset. These results may help promote and implement policies to mitigate future temperature increases and the burden of disease caused by global warming.

3-D assessment of gaze-induced eye shape deformations and downgaze-induced vitreous chamber volume increase in highly myopic eyes with staphyloma

PURPOSE

To determine if the stress of normal eye movements results in gaze-induced globe deformations, vitreous chamber axial length and vitreous chamber axial volume (VCAV) change in highly myopic eyes.

METHODS

A prospective imaging study was performed on 82 eyes of 43 patients with high myopia (>27 mm of axial length) with a clinical diagnosis of staphyloma. Three-dimensional MRI scans were acquired while subjects gazed in five directions (primary, nasal, temporal, superior and inferior). Surface renderings were generated, and a processing pipeline was created to automate alignment of the eye and to measure VCAV within 5.5 mm of the visual axis for each eye in every gaze. The degree of gaze-induced globe deformation was determined by calculating the Dice coefficient to assess the degree of overlap of the sclera at each eccentric gaze with that found in primary gaze. Each eccentric gaze VCAV was compared to VCAV in primary gaze using a fixed-effects regression allowing for subject-specific and eye-specific effects.

RESULTS

The Dice coefficient showed significant gaze-induced eye shape changes in all gazes (all p<0.0001). There were no statistically significant gaze-induced VCAV changes when comparing primary gaze to nasal, temporal or upgaze. However, when changing from primary to downgaze, VCAV was increased by +4.79 mm³ (p=0.002, 95% CI 1.71 to 7.86).

CONCLUSION

Significant gaze-induced globe deformation was noted in all gazes, but a reversible, instantaneous VCAV increase occurred only in downgaze, which is consistent with studies supporting the association of environmental factors such as near work with myopia development and progression.

Clinical spectrum of non-syndromic microphthalmos, anophthalmos and coloboma in the paediatric population: a multicentric study from North India

AIMS

To describe the clinical features, visual acuity and causes of ocular morbidity in children (0-18 years) with microphthalmos, anophthalmos, and coloboma (MAC) from North India.

METHODS

A retrospective study conducted between October 2017 and September 2018 in three tertiary eye institutes, part of the Bodhya Eye Consortium with consensus led common pro formas. Children with complete clinical data and without syndromic/systemic involvement were included. The clinical phenotype was divided into isolated ocular coloboma (CB), coloboma with microcornea (CBMC), colobomatous microphthalmos (CBMO), non-colobomatous microphthalmos (MO) and anophthalmos (AO).

RESULTS

A total of 532 children with MAC were examined. Seventeen records were excluded due to incomplete data (0.2%). 515 children (845 eyes) were included: 54.4% males and 45.6% females. MAC was unilateral in 36% and bilateral in 64%. CB, CBMC, CBMO, MO and AO were seen in 26.4%, 31%, 22%, 8% and 12.5% of eyes, respectively. Nystagmus was found in 40%, strabismus in 23%, cataract in 18.7% and retinal detachment in 15%. Best-corrected visual acuity (BCVA) of <3/60 was seen in 62.4% eyes. Blindness (BCVA <3/60 in better eye) was seen in 42.8% of bilateral patients. Those with microcornea or microphthalmos with coloboma had worse BCVA (p<0.001). There were regional differences in the type of MAC phenotype presenting to the three institutes.

CONCLUSION

The MAC group of disorders cause significant ocular morbidity. The presence of microcornea or microphthalmos with coloboma predicts worse BCVA. The variation of the MAC phenotype with the district of origin of the patient raises questions of aetiology and is subject to further studies.

Knowledge, attitudes and eye health-seeking behaviours in a population-based sample of people with diabetes in rural China

AIMS

To assess knowledge of diabetes and acceptance of eye care among people with diabetes in rural China, to improve service uptake.

METHODS

Population-based study of people in Guangdong, China, with glycosylated haemoglobin A1c≥6.5% and/or known history of diabetes. Between August and November 2014, participants answered a questionnaire (based on Delphi process/previous focus groups) on medical history, demographic characteristics, self-rated health and vision, knowledge about diabetes and diabetic retinopathy, quality of local healthcare, barriers to treatment, likely acceptance of eye exams and treatment, and interventions rated most likely to improve service uptake. Presenting visual acuity was assessed, fundus photography performed and images graded by trained graders. Potential predictors of accepting care were evaluated and confounders adjusted for using logistic regression.

RESULTS

A total of 562 people (9.6% (256/5825), mean age 66.2±9.84 years, 207 (36.8%) men) had diabetes, 118 (22.3%) previously diagnosed. 'Very likely' or 'likely' acceptance of laser treatment (140/530=26.4%) was lower than for eye exams (317/530=59.8%, p<0.001). Predictors of accepting both exams and laser included younger age (p<.001) and prior awareness of diabetes diagnosis (p=0.004 and p=0.035, respectively). The leading barrier to receiving diabetes treatment was unawareness of diagnosis (409/454, 97.2%), while interventions rated most likely to improve acceptance of eye exams included reimbursement of travel costs (387/562, 73.0%), video or other health education (359/562, 67.7%) and phone call reminders (346/562, 65.3%).

CONCLUSIONS

Improving diagnosis of diabetes, along with incentives, education and communication strategies, is most likely to enhance poor acceptance of diabetic eye care in this setting.

National approaches to trichiasis surgical follow-up, outcome assessment and surgeon audit in trachoma-endemic countries in Africa

BACKGROUND

Poor outcomes of trichiasis surgery, including postoperative trichiasis, are common in many trachoma-endemic countries in Africa. To improve outcomes, WHO recommends regular follow-up and outcome assessment of surgical cases plus audit of trichiasis surgeons.

AIMS

To assess national approaches to trichiasis surgical follow-up, outcome assessment and audit, and identify national targets for good surgical outcome (defined as the percentage of patients undergoing surgery for trichiasis remaining free of post-operative trichiasis for a defined interval after surgery).

METHODS

A cross-sectional survey was carried out between May and July 2018, involving all 29 known-trachoma-endemic countries in Africa. An emailed questionnaire was used to collect information on national targets for surgical outcomes, policies, monitoring and strategies to address underperformance by surgeons.

RESULTS

All national programmes provided information; 2 of the 29 had not yet implemented trichiasis surgery as part of their trachoma elimination programme. Findings from 27 countries are therefore reported. Only four countries reported having a national policy for trichiasis surgery follow-up and outcome assessment and only two had a national policy for conducting audits of trichiasis surgeons. Only 9 of the 27 countries had a cut-off point at which poorly performing surgeons would be instructed to discontinue surgery until retraining or other interventions had been undertaken.

DISCUSSION

To address the challenge of post-operative trichiasis and other poor outcomes, national trachoma programmes should create and implement policies and systems to follow up patients, assess surgical outcomes and monitor the performance of individual surgeons through post-surgical audits.

A randomised controlled trial comparing femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: 12-month results

AIMS

To report 12-month outcomes of randomised controlled trial comparing conventional phacoemulsification surgery (CPS) with femtosecond laser-assisted cataract surgery (FLACS).

METHODS

This was a single-centre, prospective single-masked randomised case-controlled trial. Four hundred patients were randomised to CPS or FLACS with the LenSx platform (Alcon Laboratories Inc.). Visual acuity, refraction, central corneal thickness, endothelial cell loss (ECL), adverse events and quality of life outcomes, using EuroQOL 5-dimensions (EQ-5D-3 L) and cataract surgery patient-reported outcome measures (PROMs) questionnaires (Cat-PROM5), were recorded.

RESULTS

Two hundred and thirty four patients (58.5%) attended 12-month follow-up (116 FLACS, 118 CPS). Mean LogMAR unaided distance visual acuity) (±SD) was 0.12 (0.18) with FLACS and 0.13 (0.19) with CPS (p=0.68; 95% Confidence Interval [CI]-0.06,0.04). Mean spherical equivalent (SE) refraction was -0.1±0.6 diopters (D) with FLACS and -0.2±0.6 D with CPS (p=0.44; 95% CI -0.09, 0.21). Mean corrected distance visual acuity (±SD) was -0.01 (0.1) with FLACS and 0(0.1) with CPS (p=0.45; 95% CI -0.04,0.02). Two patients per group underwent YAG laser capsulotomy for posterior capsular opacification (p=1). Mean ECL (per mm²±SD) was 301±320 with FLACS and 228±303 with CPS (p=0.07; 95% CI -7.26, 153.26). Mean Cat-PROM scores (±SD) were -5.5 (2.6) with FLACS and -5.8 (2.5) with CPS (p=0.3; 95% CI 0.31,1.01). EQ5-3DL mean index score (±SD) was 0.92 (0.13) with FLACS and 0.89 (0.14) with CPS (p=0.1; 95% CI -0.1, 0.01). Vector analysis comparing manual limbal relaxing incisions (LRIs) and intrastromal femtosecond laser-assisted astigmatic keratotomies (iFAKs) showed a greater correction index (p=0.02; 95% CI 0.06 to 0.60) and smaller difference vector (p=0.046; 95% CI -0.54, -0.01) with iFAK.

CONCLUSIONS

There were no differences in vision, refraction, adverse postoperative events or PROMs between FLACS and CPS groups at 12 months. iFAKs may provide more effective astigmatic correction compared to LRIs, 12 months postoperatively.

In vivo ocular biomechanical compliance in thyroid eye disease

BACKGROUND/AIMS

To compare the ocular biomechanical properties in patients with thyroid eye disease (TED) and healthy participants using a non-contact Scheimpflug-based tonometer (CorVis ST).

METHODS

All eyes were examined by slit lamp biomicroscopy, corneal tomography and the CorVis ST (CST). Patients with TED were examined by a fellowship trained oculoplastics specialist to determine status and assess severity. The outputs from CST and additionally derived parameters, including maximum orbital deformation (MOD), were compared between healthy participants and patients with TED using Student's t-test. Furthermore, a multiple linear regression analysis was used to control for various factors known to influence ocular biomechanical responses to an air pulse.

RESULTS

This study included 20 patients with TED and compared them with a cohort of 152 healthy participants. The mean age of patients with TED was 46.7±19.0 years and the mean age of healthy participants was 35.9±13.8 years (p=0.03). There were no statistically significant differences in gender distributions between both groups (p>0.05). Several CST parameters were significantly different between groups (p<0.05). Of note, however, MOD was significantly lower in patients with TED (0.16±0.04 mm) compared with the healthy participants (0.25±0.05 mm, p<0.001). This dissimilarity remained even after controlling for the various cofactors. Receiver-operating characteristic analysis revealed an area under the curve of 0.91±0.04 (95% CI 0.84 to 0.98, p<0.001) for MOD.

CONCLUSIONS

The in vivo ocular biomechanics as measured by the CST reflects a reduced orbital compliance. This method of ocular biomechanical assessment may aid in the categorisation of TED severity and assist in monitoring and/or diagnosing TED.

Availability of evidence on cataract in low/middle-income settings: a review of reviews using evidence gap maps approach

Background

Despite high-quality evidence being essential for planning and delivering eye health programmes, evidence on what works is relatively scarce. To address this need, we developed eye health Evidence Gap Maps (EGMs) with the first one focusing on cataract. These maps summarise, critically appraise and present evidence in a user-friendly format. This paper presents experiences of developing the cataract gap map and discusses the challenges and benefits of the process.

Methods

Following a comprehensive search of relevant databases, we sifted and extracted data from all relevant reviews on cataract. Critical appraisal was conducted by two reviewers independently using Supported the Use of Research Evidence checklist and a summary quality assessment was shared with the authors for comments.

Results

A total of 52 reviews were included in the map. The majority of the reviews addressed quality of clinical care (20) and types of treatment (18). Overall, 30 reviews provided strong evidence in response to the research question, 14 reviews showed weak or no evidence and in 14 reviews the results were inconclusive. 14 reviews were regarded as high quality, 12 were medium quality and 26 were graded as low quality. To verify the validity of the Supporting the Use for Research Evidence (SURE) checklist, studies were also appraised using the Scottish Intercollegiate Guidelines Network (SIGN) tool. Based on the κ statistics test, results showed excellent agreement between the two checklists (K=0.79).

Discussion

EGMs support policy makers and programme managers to make informed decisions and enable researchers to prioritise future work based on the most evident gaps on knowledge.

Endophthalmitis caused by Gram-positive organisms with reduced vancomycin susceptibility: literature review and options for treatment

BACKGROUND

Endophthalmitis caused by Gram-positive organisms with reduced vancomycin susceptibility and/or resistance is an important clinical issue worldwide.

PURPOSE

To review the published literature on endophthalmitis caused by Gram-positive organisms with reduced vancomycin susceptibility and/or vancomycin resistance.

METHODS

The data were analysed from a PubMed search of endophthalmitis cases caused by Gram-positive organisms with reported reduced vancomycin susceptibility and/or vancomycin resistance from 1990 to 2015.

RESULTS

From 18 publications identified, a total of 27 endophthalmitis cases caused by Gram-positive organisms with reduced vancomycin susceptibility and/or vancomycin resistance were identified. The aetiologies of endophthalmitis were exogenous in 19/27 cases (11 post-cataract surgery, 2 post-penetrating keratoplasty, 1 post-glaucoma surgery, 4 post-open globe injury, 1 post-intravitreal injection of ranibizumab), and endogenous in 4/24 cases; no details were available about the four remaining patients. The causative organisms included Enterococcus species (7/27), coagulase-negative staphylococci (4/27), Staphylococcus aureus (4/27), Bacillus species (4/27), Streptococcus species (3/27), Leuconostoc species (3/27), Staphylococcus hominis (1/27), and unidentified Gram-positive cocci (1/27). Visual acuity of 20/400 or better at the final follow-up was recorded in 10/26 patients (38.5%; data were not available for one patient). Treatment options include fluoroquinolones, penicillin, cephalosporins, tetracyclines, and oxazolidinones.

CONCLUSIONS

In the current study, visual acuity outcomes were generally poor. Enterococcus and Staphylococcus species were the most common organisms reported and postoperative endophthalmitis after cataract surgery was the most common clinical setting.

The height of the posterior staphyloma and corneal hysteresis is associated with the scleral thickness at the staphyloma region in highly myopic normal-tension glaucoma eyes

AIMS

To evaluate the characteristics of the posterior segments of eyes with high myopia and normal-tension glaucoma (NTG) and identify which ocular factors are most associated with scleral thickness and posterior staphyloma height.

METHODS

The study included 45 patients with highly myopic NTG and 38 controls with highly myopic eyes (≤-6D or axial length ≥26.0 mm). The subfoveal retinal, choroidal, scleral thickness and the posterior staphyloma heights were examined from enhanced depth imaging spectral-domain optical coherence tomography and compared between two groups.

RESULTS

Highly myopic NTG eyes had thinner subfoveal scleral thickness (473.03±43.75 vs 579.46±75.87 µm, p<0.001) and higher posterior staphyloma (97.80±70.10 vs 62.83±32.01 µm, p=0.027) than highly myopic, non-glaucomatous eyes. Subfoveal scleral thickness was significantly correlated with age, axial length, corneal hysteresis and the posterior staphyloma height of the superior quadrant, the nasal quadrant and the arithmetic mean of four quadrants in highly myopic NTG eyes. Corneal hysteresis (β=2.694, p=0.015), corneal resistance factor (β=-2.916, p=0.010) and the posterior staphyloma height of the nasal quadrant (β=-0.463, p=0.017) were significantly associated with the subfoveal scleral thickness in highly myopic NTG eyes.

CONCLUSION

Subfoveal scleral thinning and non-uniform posterior staphyloma were closely related in highly myopic NTG eyes. Corneal hysteresis, corneal resistance factor and the nasal posterior staphyloma height were associated with the scleral thickness.

Agreement between novice and experienced trachoma graders improves after a single day of didactic training

BACKGROUND/AIMS

Prevalence estimates and treatment decisions for trachoma are based entirely on ocular clinical examination. The aim of the current study is to demonstrate that ophthalmic assistants can be trained and certified to provide trachoma grading within a single day.

METHODS

Conjunctival photographs from an area with endemic trachoma were randomised into two sets of 60 cases. Photographs were graded for trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI) by three experienced graders. Inter-rater reliability of eight ophthalmic assistants and three experienced graders were compared before and after training.

RESULTS

The mean κ agreement between the ophthalmic assistants and the consensus grades of the experienced graders for TF was 0.38 (95% CI 0.18 to 0.58) before training, and increased to 0.60 (95% CI 0.42 to 0.78) after training (p=0.07). The mean κ agreement for TI was 0.16 (95% CI 0.02 to 0.30) before training, and increased to 0.39 (95% CI 0.20 to 0.58) after training (p=0.02).

CONCLUSION

A single day of training improves agreement between prospective and experienced trachoma graders, and provides the basis for certification of workers who are able to accurately grade trachoma and generate reliable prevalence estimates.

Detection of tumour cells in the bloodstream of patients with uveal melanoma: influence of surgical manipulation on the dissemination of tumour cells in the bloodstream

AIM

The detection of circulating tumour cells in the bloodstream before and after surgical manipulation, and the qualitative detection of potential shedding of tumour cells during surgical manipulation of patients with uveal melanoma.

METHODS

202 patients treated for a newly diagnosed uveal melanoma were included in the study. Blood samples were acquired 24 h before and 30 min after the basic surgical steps. Detection of potential circulating melanoma cells was extrapolated from the presence of tyrosinase and MelanA/Mart1 transcripts by reverse transcription PCR.

RESULTS

Based on the measurement of tyrosinase transcripts, as a result of the first and second surgical manipulation there were three and zero transitions from negative to positive respectively, while there were two and one transitions from positive to negative, respectively. According to MelanA/Mart1 transcripts, there were 19 and 5 transitions from negative to positive respectively, and 15 and 2 transitions from positive to negative, respectively. No statistically significant differences were documented, concerning the presence of circulating tumour cells in the blood samples acquired before and after the first surgical manipulation or the second one.

CONCLUSION

The change in the percentage of patients with detected tumour cells in their bloodstream was not statistically significant. The frequent shifts from negative to positive samples as well as from positive to negative samples comparing preoperative to postoperative samples indicates discontinuous shedding or variation due to measurements close to the threshold of detection. As a conclusion, the surgical manipulation does not seem to have a measurable contribution to the spread of melanoma cells in the bloodstream.

Comparison of high-risk histopathological features in eyes with primary or secondary enucleation for retinoblastoma

AIMS

To compare high-risk histopathology of eyes with primary versus secondary enucleation from patients with retinoblastoma.

PATIENTS AND METHODS

A retrospective histopathology review identified 207 eyes enucleated from 202 patients between March 1997 and August 2013. Our review considered high-risk histopathological features to include extraocular disease or invasion of the anterior chamber, iris, ciliary body, choroid (massive), postlaminar optic nerve or sclera.

RESULTS

Most eyes (144, 70%) were primarily enucleated; 63 (30%) were secondarily enucleated after neoadjuvant therapy. The primary enucleation group had more advanced disease (Reese-Ellsworth group V: 95% vs 59%; International Classification Group D/E: 97% vs 59%; p<0.001). The incidence of high-risk histopathology features was similar between groups (32% vs 21%, n=59; p=0.132). The type of prior therapy was not associated with high-risk histopathology features. Time to enucleation was longer for secondarily enucleated eyes with high-risk features. Choroid and postlaminar optic nerve invasion were more frequent in eyes primarily enucleated (p<0.001). Forty-six of the 59 (78%) patients with high-risk features received adjuvant chemotherapy and/or external beam radiation therapy. Three patients who received primary enucleation and adjuvant therapy died of metastatic recurrence.

CONCLUSIONS

Despite the more favourable classification of eyes treated with neoadjuvant therapy, the risk of high-risk histopathology features at enucleation was comparable with eyes undergoing primary enucleation. Delayed enucleation was associated with these features, and the majority of patients required further adjuvant therapy. Caution must be exercised in treating recalcitrant intraocular retinoblastoma to promptly pursue definitive enucleation in an effort to minimise further treatment exposures and metastases.

A brief review of Boston type-1 and osteo-odonto keratoprostheses

Globally there are ≈4.9 million bilaterally corneal blind and 23 million unilaterally corneal blind. Majority of this blindness exists in the developing countries, where resources for corneal banking and transplant surgery are less than adequate. Survival of corneal grafts gradually declines over the long term. Corneal transplantation has poor prognosis in vascularised corneal beds, ocular surface disease and viral keratitis. Keratoprosthesis (KPro) remains as a final option for end-stage ocular surface disease, multiple corneal transplant failures and high-risk corneal grafts. Boston type-1 KPro and osteo-odonto-keratoprosthesis are the two devices proven useful in recent years. Choice of a keratoprosthetic device is patient specific based on the underlying diagnosis, ocular morbidity and patient suitability. KPro surgery demands a high level of clinical and surgical expertise, lifelong commitment and extensive resources. Improvements in techniques and biomaterials may in the future provide retainable KPros that do not need regular follow-up of patients, have low complications but high retention rates and may be produced at a low cost on a mass scale to be available as 'off the shelf' devices. Because KPros have the potential to effectively address the burden of surgically treatable corneal blindness and may also eliminate the problems of corneal transplantation, more research is required to develop KPros as substitutes for corneal transplantation even in low-risk cases. In those countries where corneal blindness is a major liability, we need a two pronged approach: one to develop eye donation, eye banking and corneal transplantation and the second to establish centres for keratoprostheses, which are affordable and technically not challenging, in a population where default on follow-up visits are high. Until the latter is achieved, KPros should be viewed as a temporary means for visual restoration and be offered in national and supraregional specialised centres only.

Estimation of ocular volume from axial length

BACKGROUND/AIMS

To determine which biometric parameters provide optimum predictive power for ocular volume.

METHODS

Sixty-seven adult subjects were scanned with a Siemens 3-T MRI scanner. Mean spherical error (MSE) (D) was measured with a Shin-Nippon autorefractor and a Zeiss IOLMaster used to measure (mm) axial length (AL), anterior chamber depth (ACD) and corneal radius (CR). Total ocular volume (TOV) was calculated from T2-weighted MRIs (voxel size 1.0 mm(3)) using an automatic voxel counting and shading algorithm. Each MR slice was subsequently edited manually in the axial, sagittal and coronal plane, the latter enabling location of the posterior pole of the crystalline lens and partitioning of TOV into anterior (AV) and posterior volume (PV) regions.

RESULTS

Mean values (±SD) for MSE (D), AL (mm), ACD (mm) and CR (mm) were -2.62±3.83, 24.51±1.47, 3.55±0.34 and 7.75±0.28, respectively. Mean values (±SD) for TOV, AV and PV (mm(3)) were 8168.21±1141.86, 1099.40±139.24 and 7068.82±1134.05, respectively. TOV showed significant correlation with MSE, AL, PV (all p<0.001), CR (p=0.043) and ACD (p=0.024). Bar CR, the correlations were shown to be wholly attributable to variation in PV. Multiple linear regression indicated that the combination of AL and CR provided optimum R(2) values of 79.4% for TOV.

CONCLUSION

Clinically useful estimations of ocular volume can be obtained from measurement of AL and CR.

Does choroidal melanoma regression correlate with chromosome 3 loss after ruthenium brachytherapy?

AIM

To determine the reduction of choroidal melanoma thickness 6 months after ruthenium 106-brachytherapy according to chromosome 3 status, which correlates strongly with metastatic death.

METHODS

Transscleral fine needle aspiration biopsy was performed prior to the insertion of a radioactive plaque if the tumour was deemed sufficiently thick and anterior for such a procedure. Transretinal biopsy with a 25-gauge vitreous cutter was performed for thin and posterior tumour within a month of plaque removal. The chromosome 3 status was determined by fluorescence in situ hybridisation from 2002 until 2006, and by either multiplex ligation-dependent probe amplification and/or microsatellite analysis after this period until the end of the study. The choroidal melanoma dimensions were obtained from outpatient visits.

RESULTS

149 eyes from 149 patients were included. The mean age was 60.8 years. 84 eyes (56.4%) had disomy 3 and 65 eyes (43.6%) monosomy 3. The median pretreatment tumour thickness was 3.0 mm in disomy 3 and 4.1 mm in monosomy 3 tumours (p=0.018). The follow-up duration medians were 6.3 months for disomy 3 and 6.4 months for monosomy 3 tumours (p=0.68). The rates of thickness reduction were 6.7% and 7.0% per month, respectively (p=0.59). Thickness reduction exceeding 50% occurred in 32 (38.1%) disomy 3 and 24 (36.9%) monosomy 3 tumours.

CONCLUSIONS

The rate of choroidal melanoma regression after ruthenium-106 brachytherapy does not appear to correlate with chromosome 3 loss, suggesting that tumour thickness reduction 6 months after treatment is unlikely to predict survival.

Ocular haemodynamics in patients with type 2 diabetes and coronary artery disease

BACKGROUND/AIMS

To assess the relationship between ocular blood flow parameters and diabetic retinopathy and coronary artery disease in diabetic patients.

METHODS

56 patients participated in the study. Colour Doppler imaging was used to assess the peak systolic and end-diastolic blood velocities as well as resistivity index in the ophthalmic, central retinal and posterior ciliary arteries. The diagnosis of coronary artery disease was based on the coronary angiogram.

RESULTS

As compared to controls, the peak systolic and end-diastolic blood velocities in all three evaluated vessels were significantly lower in the case of diabetic patients with coronary artery disease. Diabetic patients without coronary artery disease showed only decreased end-diastolic velocity values in the ophthalmic artery compared with the controls. Among diabetic patients, coronary artery disease was related to lower peak systolic and end-diastolic velocities in the central retinal artery and peak systolic velocities in the short posterior ciliary arteries. Diabetic retinopathy was significantly associated with a further decrease in end-diastolic blood velocity and an increase in resistivity index in the central retinal artery.

CONCLUSIONS

(1) Flow disturbances within the ocular blood vessels of patients with type 2 diabetes were associated with atherogenic changes of coronary arteries. (2) In patients with type 2 diabetes and concomitant coronary artery disease, impaired blood flow within the ophthalmic and short posterior ciliary arteries was not related to diabetic retinopathy, but diabetic retinopathy was related to additional blood flow impairment within the central retinal artery.

Does restoration of binocular vision make any difference in the quality of life in adult strabismus

BACKGROUND

To report the effect of restoration of binocular functions in adult strabismus on the health-related quality of life (HRQOL).

METHODS

61 adults undergoing strabismus surgery completed Adult Strabismus-20 (AS-20) and Amblyopia and Strabismus (A&SQ) HRQOL questionnaires preoperatively and postoperatively. Patients were grouped according to their responses to binocular tests as binocular vision positive (BVP) and binocular vision negative (BVN) groups. Changes in AS-20 and A&SQ scores of the overall group and the subgroups were evaluated.

RESULTS

Motor success was 90%, and 43% of the cohort showed measurable level stereopsis and central fusion on the Worth four-dot test or on the synoptophore. HRQOL scores (composite, psychosocial and functional) of the cohort measured by AS-20 and A&SQ showed significant improvement after surgery (AS-20: 42,40,45 vs 85,86,84, AS&Q: 46,52,38 vs 76,75,78, p<0.05 for all comparisons). But the BVP (n-26) group was not found superior to the BVN (n-35) group both functionally and psychosocially (p>0.05). Only after the exclusion of the amblyopic patients, functional superiority of the BVP group (n-20) over the BVN group (n-20) was disclosed (AS-20: 45 vs 31, A&SQ: 28 vs 16, p<0.05), while the composite and psychosocial subscale score improvements were not different (AS-20: 44,40 vs 34,38, A&SQ: 30,38 vs 20,37, p>0.05 for all comparisons).

CONCLUSIONS

The restoration of binocular vision is possible in adults with a long-term history of strabismus and both AS-20 and A&SQ questionnaires are sensitive to detect additive effect of binocular vision on functional aspects of the quality of life. To increase this sensitivity, questionnaires can be modified to include items inquiring tasks that require fine stereopsis.

Intra-operative decision making by ophthalmic surgeons

PURPOSE

Research on surgical decision making and risk management usually focuses on peri-operative care, despite the magnitude and frequency of intra-operative risks. The aim of this study was to examine ophthalmic surgeons' intra-operative decisions and risk management strategies in order to explore differences in cognitive processes.

METHOD

Critical decision method interviews were conducted with 12 consultant ophthalmologists who recalled cases and selected important decisions during the operations. These decisions were then discussed in detail in relation to decision making style and risk management. Transcripts were coded according to decision making strategy (analytical, recognition primed decision, creative and rule-based) and risk management (threats, risk assessment and risk tolerance).

RESULTS

The key decision in each case was made using either a rapid, intuitive mode of thinking (n=6, 50%) or a more deliberate comparison of alternative courses of action (n=6, 50%). Rule-based or creative decision making was not used. Risk management involved the perception of threats and assessment of threat impact but was also influenced by personal risk tolerance. Risk tolerance seemed to play a major role during situations requiring a stopping rule. Risk management did not appear to be influenced by time pressure.

CONCLUSIONS

Surgeons described making key intra-operative decisions using either an intuitive or an analytical mode of thinking. Ophthalmic surgeons' risk assessment, risk tolerance and decision strategies appear to be influenced by personality.

Familial acorea, microphthalmia and cataract syndrome

PURPOSE

To describe the clinical features of members of a family with acorea, microphthalmia and cataract syndrome. In addition, to perform linkage analysis on family members to determine possible candidate genes.

METHODS

Comprehensive ophthalmic examinations were performed on five affected members of a family consisting of a paternal grandmother, father and three children. In addition, DNA was extracted from nine family members (the five affected and four normal members) and used for genome-wide single nucleotide polymorphism genotyping and linkage analysis.

RESULTS

All of the affected patients had acorea or fibrous occlusion of the pupil, microphthalmia and cataracts in both eyes. They also had microcornea and iridocorneal dysgenesis. Examination of the crystalline lens was hindered by the abnormal iris surface, but cataracts were detected by ultrasound biomicroscopy. Surgical reconstruction of the pupil allowed a better view of the posterior pole of the eye, and ophthalmoscopy showed a normal retina and optic disc. No systemic abnormalities were observed. Linkage analysis did not reach significance but narrowed the location of possible candidate genes to chromosomes 1, 5, 8, 11 and 17.

CONCLUSIONS

This acorea, microphthalmia and cataract syndrome has not previously been reported. Genetic analyses indicate that this syndrome is probably due to an autosomal dominant mutation.

The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology

BACKGROUND

To investigate the effect of a structured, supervised, cataract simulation programme on ophthalmic surgeons in their first year of training, and to evaluate the level of skill transfer.

METHODS

Trainees with minimal intraocular and simulator experience in their first year of ophthalmology undertook a structured, sequential, customised, virtual reality (VR) cataract training programme developed through the International Forum of Ophthalmic Simulation. A set of one-handed, bimanual, static and dynamic tasks were evaluated before and after the course and scores obtained. Statistical significance was evaluated with the Wilcoxon sign-rank test.

RESULTS

The median precourse score of 101.50/400 (IQR 58.75-145.75) was significantly improved after completing the training programme ((postcourse score: 302/400, range: 266.25-343), p<0.001). While improvement was evident and found to be statistically significant in all parameters, greatest improvements were found for capsulorhexis and antitremor training ((Capsulorhexis: precourse score=0/100, range 0-4.5; postcourse score=81/100, range 13-87.75; p=0.002), (antitremor training: precourse score=0/100, range 0-0; postcourse score=80/100, range 60.25-91.50; p=0.001)).

CONCLUSIONS

Structured and supervised VR training can offer a significant level of skills transfer to novice ophthalmic surgeons. VR training at the earliest stage of ophthalmic surgical training may, therefore, be of benefit.

Pattern of ocular injuries in stone pelters in Kashmir valley

PURPOSE

To describe the pattern and types of ocular injuries in stone pelters in Kashmir valley during recent turmoil.

DESIGN

Cross sectional study.

METHODS

Sixty patients with different types of eye injuries were assessed between June-September 2010 and initial visual acuity was recorded. The injuries were classified according to Systems for Classifying Ocular Injuries (OTCS) and Ocular Trauma Score (OTS) was calculated in order to estimate the probability of follow-up visual acuity range.

RESULTS

Most of the victims (75%) were young boys between 16-26 years with a mean age of 20.95, 95% of cases were males. The main cause of injury was stones (48.3%) and pellets (30%) besides rubber bullets, sling shots and tear gas shells. Most of the open-globe injuries due to stones were of Type B and A, Grade E, Zone II and III with Afferent Pupillary Defect (APD) in 30% of the cases. Closed-globe injuries were mostly of Type A, Grade C and D and Zone II and III. Most of the open-globe injuries due to pellets were of Type D, Grade D, Zone II and APD in 33.3%. Pellets Intra Ocular Foreign Body (IOFB) was in 41.6%. Most of the closed-globe injuries were of Type A, Grade D and E and of Zone III. Overall OTS of 1 was calculated in 16.6% and 3 in 53.3% of the cases.

CONCLUSION

In stone pelting demonstrations eye injuries can result in visually significant trauma. Injuries due to pellets are mostly perforating and pellet IOFB, and both tend to have a very poor prognosis. OTS can be used to estimate visual prognosis.