Retrospective analyses of routine preoperative blood testing in a tertiary eye hospital: could Choosing Wisely work in China?

AIMS

To explore the possibility of implementing Choosing Wisely on ocular patients in China by investigating the prevalence of abnormalities in routine preoperative blood tests (RPBTs) and its turnaround time (TAT).

METHODS

Data from 102 542 ocular patients between January 2016 and December 2018, at Zhongshan Ophthalmic Center, were pooled from the laboratory information system. The test results were divided into normal and abnormal, including critical values. Ocular diseases were stratified into 11 subtypes based on the primary diagnosis. The TAT of 243 350 blood tests from January 2017 to December 2018 was categorised into transportation time and intralaboratory time.

RESULTS

RPBT was grouped into complete blood count (CBC), blood biochemistry (BBC), blood coagulation (BCG) and blood-borne pathogens (BBP), completed for 97.22%, 87.66%, 94.41% and 95.35% of the recruited patients (male, 52 549 (51.25%); median(IQR) age, 54 (29-67) years), respectively. Stratified by the test items, 9.19% (95% CI 9.07% to 9.31%) were abnormal results, and 0.020% (95% CI 0.019% to 0.022%) were critical; most abnormalities were on the CBC, while glucose was the most common critical item. Classified by the patients' primary diagnosis, 76.97% (95% CI 76.71% to 77.23%) had at least one abnormal result, and 0.28% (95% CI 0.25% to 0.32%) were critical; abnormal findings were reported in 45.29% (95% CI 44.98% to 45.60%), 54.97% (95% CI 54.65% to 55.30%), 30.29% (95% CI 30.00% to 30.58%) and 11.32% (95% CI 11.12% to 11.52%) for the CBC, BBC, BCG and BBP tests, respectively. The median transportation time and intralaboratory TAT of the samples were 12 min and 78 min respectively.

CONCLUSION

Blood abnormalities are common in ocular patients. With acceptable timelines, RPBT is still indispensable in China for patient safety.

Scleral growth stunting via sub-Tenon injection of cross-linking solutions in live rabbits

BACKGROUND

Scleral cross-linking is a potential method to inhibit axial elongation of the eye, preventing the progression of pathological myopia. Formaldehyde releasers, which are common preservatives found in cosmetics and ophthalmic solutions, have been shown to be not only effective in cross-linking corneal collagen in vitro and in vivo, but also have minimal toxicity effects on the eye. The present study aims to evaluate the efficacy of scleral cross-linking using sodium hydroxymethylglycinate (SMG) to inhibit eye growth using an in vivo rabbit model.

METHODS

A cross-linking solution containing 40 mM SMG was delivered to the sub-Tenon's space behind the equator. The application regimen included a two-quadrant injection performed five times over 2 weeks on New Zealand White rabbits (n=5, group 1), and one-time injection followed for up to 5 days on Dutch-Belted rabbits (n=6, group 2). Group 1 was monitored serially for axial length changes using B-scan ultrasound for 5-6 weeks. Group 2 was injected with a higher viscosity solution formulation. Both groups were evaluated for thermal denaturation temperature changes of the sclera postmortem.

RESULTS

Axial growth was limited by 10%-20% following SMG treatment as compared with the untreated eye. Thermal denaturation analysis showed increased heat resistance of the treated eyes in the areas of injection. Overall, the SMG treatment inhibited eye growth with few side effects from the injections.

CONCLUSIONS

Cross-linking solutions delivered via sub-Tenon injection provide a potential method for limiting axial length growth in progressive myopia and could be used as a potential treatment for myopia.

Impact of personal protective equipment on the clarity of vision among trachoma survey graders and trichiasis surgeons in the context of COVID-19

BACKGROUND/AIMS

The COVID-19 pandemic necessitated the use of personal protective equipment for those involved in trachoma survey grading and trichiasis surgery. We sought to determine which configuration of a face shield would be less likely to impact grading accuracy and ability to conduct trichiasis surgery. The research also included assessment of comfort, ease of cleaning and robustness.

METHODS

There were three research phases. In phase 1, assessment of four potential face shield configurations was undertaken with principal trachoma graders and trichiasis surgeon trainers to decide which two options should undergo further testing. In phase 2, clarity of vision and comfort (in a classroom environment) of the two configurations were assessed compared with no face shield (control), while grading trachomatous inflammation-follicular (TF). The second phase also included the assessment of impact of the configurations while performing trichiasis surgery using a training model. In phase 3, face shield ease of use was evaluated during routine surgical programmes.

RESULTS

In phase 2, 124 trachoma graders and 28 trichiasis surgeons evaluated the 2 face shield configurations selected in phase 1. TF agreement was high (kappa=0.83 and 0.82) for both configurations compared with not wearing a face shield. Comfort was reported as good by 51% and 32% of graders using the two configurations. Trichiasis skill scores were similar for both configurations.

CONCLUSION

The face shield configuration that includes a cut-out for mounting the 2.5× magnifying loupes does not appear to impact the ability or comfort of trachoma graders or trichiasis surgeons to carry out their work.

Prevalence of self-reported chronic conditions and poor health among older adults with and without vision impairment in China: a nationally representative cross-sectional survey

Objective

To examine the self-reported prevalence of 13 chronic conditions and poor health among Chinese adults aged 45 years and older with and without self-reported vision impairment.

Design

Cross-sectional study from the China Health and Retirement Longitudinal Study 2018, a nationally representative survey of Chinese adults aged 45 years and older involving 19 374 participants.

Methods

We used logistic regression to assess the association between vision impairment and 13 common chronic conditions and between vision impairment and poor health for those with any of these chronic conditions.

Results

Older people with self-reported vision impairment were significantly more likely to report all 13 chronic conditions (all p<0·05). After controlling for age, gender, education, residential status (rural vs urban), smoking and BMI, the highest adjusted odds were for hearing impairment (OR=4.00 (95% CI 3·60 to 4·44]) and depression (OR=2.28 (95% CI 2.06 to 2.51)). The lowest risk, though still significant, was for diabetes (OR=1·33 (95% CI 1.11 to 2.05)) and hypertension (OR=1.20 (95% CI 1.04 to 1.38)). After controlling for these potential confounding factors, among older people with chronic conditions, those with vision impairment were 2.20 to 4.04 times more likely to have poor health, compared with those without vision impairment (all p<0.001), with the exception of cancer (p=0.595).

Conclusions

Higher prevalence of chronic conditions is strongly associated with vision impairment among older Chinese adults and poor health is strongly associated with vision impairment among people with chronic conditions.

Prevalence and associated factors of symptomatic dry eye among undergraduate students in Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia

Objective

This study aimed to assess the prevalence and associated factors of symptomatic dry eye (SDE) among undergraduate students at the College of Medicine and Health Science, Hawassa University, Ethiopia.

Methods and analysis

Institution-based cross-sectional study was conducted using a systematic random sampling technique. A total of 311 undergraduate students were recruited to execute the study. Ethical clearance was obtained from the ethical review committee of the school of Medicine and Health Science. A standardised self-administered questionnaire was used to collect the data. Data were entered using Epi Info V.7 and cleaned and analysed using SPSS V.23. Binary and multivariable logistic regression analysis was done to select candidate variables and to identify statistically significant factors. Variables with a p value of <0.05 on multivariable analysis were reported as statistically significant.

Results and conclusion

The overall prevalence of SDE was found to be 49.4% (95% CI 43.7% to 55.1%). In this study, the history of ophthalmic drop use (adjusted OR, AOR 2.063; 95% CI 1.073 to 3.957) and being second (AOR 5.99; 95% CI 1.10 to 32.56) and third (AOR 11.55; 95% CI 2.12 to 62.94) year student were factors that significantly associated with SDE.

In this study, the prevalence of SDE was significantly high. The factors associated with SDE were the use of ophthalmic drops and the class year of students. Therefore, public health education about protective measures should be considered to minimise the effects of SDE on the quality of life of students.

Investigating the need and structure for a comprehensive eye care competency framework

Objective

The objective of this paper is to establish whether existing eye care competency frameworks (ECCF) are fit for purpose, and set out a comprehensive ECCF that better meets the needs of the eye care workforce and broader population.

Methods and analysis

We carried out a two-stage process. The first was to conduct a desk review of existing frameworks and models relevant to eye care competencies. The second was to conduct a broad stakeholder consultation of global eye care experts to affirm the gaps found in the first stage, and to inform the development of a comprehensive ECCF.

Results

We reviewed 52 competency frameworks, competency standards and models related to eye care (including 11 from the UK) and found that there were three types of gaps, such as: (1) narrow in focus on specific occupational groups; (2) limitations in the competencies expected from an eye care worker and (3) limitations in regional focus, such that they could not easily be applied in a global context.

Having affirmed these gaps during the stakeholder consultation stage, we developed a more comprehensive ECCF structure, which composed of six domains: practice, professionalism, learning and development, management and leadership, community and advocacy, and evidence. This broader structure seeks to address the gaps found in the desk review.

Conclusion

The review showed that there was a need to develop a comprehensive ECCF that can be easily contextualised, encapsulate the roles of the diverse eye care workforce, and be a tool for eye care workforce planning and development to meet the needs of a global population.

Expression of Ki67 as detected by MIB-1 and its association with histopathological high-risk factors among patients with retinoblastoma tumour: a cross-sectional study

Objectives

This study aims to investigate the expression of Ki67 in formalin-fixed paraffin-embedded tissue blocks from patients with a diagnosis of retinoblastoma tumour (RbT) as well as determining its association with histopathological high-risk factors (HHRFs).

Methods and analysis

Retrospectively, a total of 194 eyeball specimens from 163 children with RbT were reviewed at Muhimbili National Hospital between 2009 and 2013. Immunohistochemical expression of Ki67 using MIB-1 antibody (Abcam, batch ab93680, Cambridge, UK) was determined and correlated with the conventional HHRFs. The predictors of Ki67 expression were determined using binary logistic regression model in multivariate analysis. A two-tailed p<0.05 was considered statistically significant.

Results

Majority (67.5%) of the patients had leukocoria and extraocular disease was found in 20.9% of all the patients. High expression of Ki67 was present in 63.8% of the 80 eyeballs that were tested. Massive choroidal invasion (adjusted OR (AOR)=9.32, 95% CI=2.82 to 10.89), positive retrolaminar optic nerve invasion (AOR=3.01, 95% CI=4.43 to 9.11), positive surgical margin (AOR=7.10, 95% CI=1.63 to 11.40) and pT4 (AOR=7.49, 95% CI=0.12 to 0.89) were the potential HHRFs that were associated with Ki67 overexpression.

Conclusion

Overexpression of Ki67 may be of prognostic value for patients with RbT as it has been shown in the present study that high expression was common in tumours with massive choroidal invasion, positive retrolaminar optic nerve invasion, positive surgical margin and advanced tumour stage, which are the conventional HHRFs associated with prognosis of RbT.

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery

PURPOSE

To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE).

DESIGN

Retrospective, sequential, clinical registry study.

METHODS

85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR.

RESULTS

Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups.

CONCLUSIONS

Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Association between the number of visual fields and the accuracy of future prediction in eyes with retinitis pigmentosa

Purpose

To evaluate the minimum number of visual fields (VFs) required to precisely predict future VFs in eyes with retinitis pigmentosa (RP).

Methods

A series of 12 VFs (Humphrey Field Analyzer 10–2 test (8.9 years in average) were analysed from 102 eyes of 52 patients with RP. The absolute error to predict the 12th VF using the prior 11 VFs was calculated in a pointwise manner, using the linear regression, and the 95% CI range was determined. Then, using 3–10 initial VFs, next VFs (4th to 11th VFs, respectively) were also predicted. The minimum number of VFs required for the mean absolute prediction error to reach the 95% CI was identified. Similar analyses were iterated for the second and third next VF predictions. Similar analyses were conducted using mean deviation (MD).

Results

In the pointwise analysis, the minimum number of VFs required to reach the 95% CI for the 12th VF was five (first and second next VF predictions) and six (third next VF prediction). For the MD analysis, three (first and second next VF predictions) and four (third next VF prediction) VFs were required to reach 95% CI for the 12th VF.

Conclusions

The minimum number of VFs required to obtain accurate predictions of the future VF was five or six in the pointwise analysis and three or four in the analysis with MD.

Histopathology-guided management of ocular surface squamous neoplasia with corneal stromal or scleral invasion using ruthenium-106 plaque brachytherapy

BACKGROUND/AIM

To evaluate the safety and efficacy of ruthenium-106 (Ru-106) plaque brachytherapy in managing invasive ocular surface squamous neoplasia (OSSN).

METHODS

This is a retrospective, non-comparative, interventional case series of 42 eyes with OSSN with histopathologically-proven corneal stromal and/or scleral invasion that underwent Ru-106 plaque brachytherapy. Main outcome measures were tumour regression, eye salvage, final visual acuity, treatment complications and metastasis.

RESULTS

At presentation, the mean tumour basal diameter was 9.3 mm (range 5-26 mm) and thickness 3.1 mm (range 1.5-11 mm). Prior treatment included excision biopsy in two patients (5%), incision biopsy and topical interferon in one each (2%). Following excision with 4 mm clinically clear margins, corneal stromal and/or scleral invasion of OSSN was confirmed in all 42 cases, with the excised base showing invasive squamous cell carcinoma. A total dose of 5000 cGy over a mean duration of 19.7 hours (range 7-41 hours) was provided to an axial depth of 2 mm using Ru-106 surface plaque. Over a mean follow-up of 36.9 months (range 22.3-72 months), complete tumour regression was achieved in all eyes (100%). Two eyes (5%) showed conjunctival tumour growth remote from the site of prior treatment. Visual acuity was maintained at ≥20/200 in 35 eyes (83%), with a loss of >2 Snellen lines in 1 eye (2%). There was no evidence of regional lymph node or systemic metastasis.

CONCLUSION

Histopathology-guided use of Ru-106 surface plaque brachytherapy is a safe and an effective adjuvant therapy in the management of corneal stromal and/or scleral invasion of OSSN.

Novel open-source 3D-printed eye mount (TEMPO) for the ophthalmology wet lab

Objective

Procuring an affordable eye mount that can stabilise a cadaveric eye and simulate a patient's normal facial contours represents an ongoing challenge in the ophthalmology simulation wet lab, with notable limitations to all currently available commercial options. This project uses computer-assisted design and three-dimensional (3D)-printing techniques to tackle these challenges for ophthalmologic surgical training.

Methods and Analysis

Proof-of-concept study. Using Autodesk Fusion 360, we designed and 3D-printed a modular device that consists of 11 pieces forming a head structure. Standard OR tubing and syringes were adapted to create an adjustable-suction system to affix cadaveric eyes. Further modular inserts were customised to house non-cadaveric simulation eyes.

Results

Three-dimensional eye mount for procedures in ophthalmology (TEMPO) reliably fixed a cadaveric eye in stable position throughout surgical manipulation. Trainees were able to drape and practice appropriate hand positioning while corneal suturing. Overall, this model was affordable, at a cost of approximately $C200 to print. The modular nature renders individual pieces convenient for replacement and customisable to simulate regional anatomical variation and accommodate non-cadaveric eyes.

Conclusions

TEMPO represents an affordable, high-fidelity alternative to existing commercially available eye mounts. It reliably fixates cadaveric and simulation eyes and provides an enhanced surgical training experience by way of its realistic facial contours. It is released as an open-source computer-aided design file, customisable to interested trainees with appropriate software and 3D-printing capacity.

Studies on the prevalence of blindness in Ethiopia: a protocol for the systematic review and meta-analysis

Introduction

Blindness refers to a lack of vision and/or defined as presenting visual acuity worse than 3/60 in the better eye. Its highest proportion has been conforming to the developing countries such as Ethiopia. So, timely information is crucial to design strategies. However, the study on the magnitude of blindness in Ethiopia was outdated, that means it was conducted in 2005–2006. Therefore, this protocol has been proposed to estimate the pooled prevalence of blindness in Ethiopia to provide up-to-date, comprehensive evidence on this theme.

Methods and analysis

The following databases will be used to search articles: PubMed, Cochrane Library, Google Scholar and retrieving references. Standard data extraction approach will be employed and presented using Preferred Reporting Items for Systematic Review and Meta-Analysis. The Newcastle–Ottawa Scale quality assessment tool will be used to evaluate the quality of studies. Analysis will be held using STATA V.11. Funnel plot and Egger’s regression test will be applied to check for the potential sources of bias. Heterogeneity among the studies will be tested using Higgins method in which I² statistics will be calculated and compared with the standard. Meta-regression and subgroup analysis will be done to identify the potential sources of heterogeneity. Cross-sectional and survey studies conducted in Ethiopia and published in English language will be included.

Ethics and dissemination

Ethics approval and consent are not required. On completion, the result will be submitted to a reputable peer-reviewed journal.

Trial registration number

CRD42021268448.

Ocular manifestations of RT-PCR-confirmed COVID-19 cases in a large database cross-sectional study

OBJECTIVE

To evaluate ocular manifestations of reverse transcriptase (RT)-PCR-confirmed SARS-CoV-2-infected patients in a validated comparative model, and additionally to evaluate the correlation between severity of COVID-19 and ocular manifestations.

METHODS AND ANALYSIS

In a prospective cross-sectional study, a total of 2400 subjects were enrolled over a period of 8 months. To eliminate bias of identical ocular symptom profile in other non-COVID-19 respiratory infections and to acquire a comparative model, 1200 COVID-19 RT-PCR-positive patients (group 1) and 1200 RT-PCR-negative patients (group 2) were included. Data collection included use of a prestructured tool and 'Google-forms', along with stratification of patients into 'mild, moderate, and severe' categories. Study subjects were evaluated for ocular manifestations by clinical examination and laboratory work-up. Univariate and multivariate logistic regression analyses were performed.

RESULTS

144 (12%) patients in group 1 had ocular symptoms as compared with 24 (2%) patients in group 2 (p<0.001). Ocular manifestations (symptoms and signs) comprising burning sensation (6.7%, p<0.001), foreign body sensation and irritation (7.0%, p<0.001), and conjunctival signs (2.7%, p<0.001) were found statistically significant in group 1 as compared with group 2. Ocular involvement increased in proportion to severity of COVID-19: mild (5.3%), moderate (24.6%) and severe (58.8%) (p=0.0006).

CONCLUSION

The frequency of occurrence of ocular manifestations was higher in group 1 as opposed to group 2. Furthermore, the presence of ocular manifestations carried a direct correlation with severity of systemic disease and presence of comorbidities.

Orbitopalpebral and ocular sarcoidosis: what does the ophthalmologist need to know

Sarcoidosis is a chronic multisystemic disease of unknown aetiology, characterised by non-caseating granulomas. Ocular involvement rate ranges from 30% to 60% among individuals with sarcoidosis, and can vary widely, making the diagnosis a challenge to the ophthalmologist. Cutaneous manifestations occur in about 22% of sarcoidosis cases, but eyelid involvement is rare. Eyelid swelling and nodules are the most frequent forms of eyelid involvement, but other findings have been reported. The joint analysis of clinical history, ancillary exams and compatible biopsy is needed for the diagnosis, as well as the exclusion of other possible conditions. This review aims to describe the different forms of presentations, the clinical reasoning and treatment options for ocular, eyelid and orbital sarcoidosis.

Improvement of asymmetric thyroid eye disease with teprotumumab

Purpose

Teprotumumab, a specific blocking antibody to the insulin like growth factor 1 receptor, significantly reduced proptosis in patients with thyroid eye disease (TED) in recent clinical trials. Given its specificity, we expect it to demonstrate greater efficacy on the worse affected orbit, in patients with asymmetric TED. Herein, we investigate the differential impact of teprotumumab on the orbits of such patients.

Methods

In this pooled analysis of patients who were enrolled in the recent phase 2 (NCT01868997) and phase 3 (NCT03298867) trials, all patients with asymmetric TED (difference in exophthalmometry of ≥3 mm) were screened for eligibility. The primary outcomes of the trials, proptosis, diplopia and Clinical Activity Score (CAS) response, were evaluated in both orbits of patients who had received treatment or placebo, to examine the differential response from baseline to week 24.

Results

From a pooled group of 84 patients randomised to receive teprotumumab and 87 randomised to placebo, 10 (12%) and 12 (14%), respectively, met the inclusion criteria. The teprotumumab-treated patients demonstrated significant reductions in proptosis, CAS and diplopia in both orbits of each patient and this was not seen with placebo. The reduction in proptosis and CAS was significantly greater in the worse affected orbit, improving symmetry. In the placebo arm, while the mean CAS in the study eye reduced over time, proptosis and diplopia did not change in either orbit.

Conclusion

The findings in this study suggest the differential impact of teprotumumab on orbits that are clinically more affected by TED, suggesting that teprotumumab reduces asymmetry.

Outcomes of enucleation and porous polyethylene orbital implant insertion in patients with paediatric retinoblastoma: a long-term follow-up study

BACKGROUND/AIMS

To report the long-term outcomes of enucleation and insertion of porous polyethylene (PP) orbital implant according to the evolving surgical techniques and implant in patients with paediatric retinoblastoma .

METHODS

Patients with paediatric retinoblastoma who underwent enucleation and PP implant insertion from December 1998 to December 2014 were retrospectively reviewed and divided into four groups: group A, classic enucleation +PP implant; group B, enucleation +PP implant +anterior closure of the posterior Tenon's (ACPT) capsule; group C, enucleation +PP implant +free orbital fat graft +ACPT and group D, enucleation +smooth surface tunnel PP implant +ACPT. Survival analysis of implant exposure and eyelid malpositions was performed.

RESULTS

One hundred and ninety-eight eyes of 196 patients were included. The median follow-up period was 13.0 years (range, 5.0-21.1). A 20 mm implant was inserted for 149 eyes (75.3%). The 10-year exposure-free survival probabilities were 44.6% in group A, 96.4% in group B, 97.4% in group C and 97.7% in group D. ACPT was associated with significant reduction in implant exposure (p<0.001). The most common eyelid malposition was upper eyelid ptosis (24.2%). The eyelid malposition-free survival probability did not differ among the four groups. However, the insertion of a 20 mm implant was associated with significant reduction in upper eyelid ptosis and lower eyelid entropion (p=0.004 and 0.038, respectively).

CONCLUSIONS

The long-term postenucleation implant exposure was rare after PP implant insertion and ACPT, even with a 20 mm-diameter implant. A larger implant can be beneficial in long-term prevention of eyelid malposition.

Sore eyes as the most significant ocular symptom experienced by people with COVID-19: a comparison between pre-COVID-19 and during COVID-19 states

OBJECTIVE

Conjunctivitis has been reported in people suffering from COVID-19. However, many ocular symptoms are associated with the term 'conjunctivitis' which may be misleading. It is also unknown whether ocular symptoms were different in chronic sufferers of anterior eye diseases, when they were experienced or how long they lasted for compared with other COVID-19 symptoms.

METHODS

An online structured questionnaire obtained self-report data from people who had a confirmed diagnosis of COVID-19. Data for the type, frequency and duration of different COVID-19 symptoms were ascertained. Anterior eye symptoms experienced by participants in the pre-COVID-19 state were compared with during the COVID-19 state.

RESULTS

Data from 83 participants showed that the most reported COVID-19 symptoms were dry cough (66%), fever (76%), fatigue (90%) and loss of smell/taste (70%). The three most common ocular symptoms experienced by participants were photophobia (18%), sore eyes (16%) and itchy eyes (17%). The frequency of sore eyes was significantly higher (p=0.002) during COVID-19 state (16%) compared with pre-COVID-19 state (5%). There were no differences between males and females (p>0.05). 81% of participants reported to have experienced ocular symptoms within 2 weeks of other COVID-19 symptoms, and 80% reported they lasted for less than 2 weeks.

CONCLUSION

The most significant ocular symptom experienced by people suffering from COVID-19 was sore eyes. Other symptoms associated with other types of conjunctivitis, such as mucous discharge and gritty eyes linked to bacterial infection, did not reach significance. The term 'conjunctivitis' is too broad and should be used with caution.

Validating e-norms methodology in ophthalmic biometry

Objective

To validate the extrapolated norms or e-norms methodology in establishing a reference range for the biometric data used for intraocular lens power calculation.

Methods and Analysis

All measurements were performed with an optical low-coherence reflectometer. A novel technique, the e-norms methodology, was used to determine the normative values of measurements.

Results

Eyes (n=500) were measured to evaluate the axial length (AL), K readings (Ks), anterior chamber depth (ACD) and lens thickness (LT). Using the e-norms methodology, the normal AL ranged from 22.50 to 24.50 mm (mean=23.50 mm), with medium-long eyes between 24.51 and 24.99 mm and the long eyes measuring 25.00 mm and longer; the medium-short eyes ranged from 22.01 and 22.49 mm, with the short eyes measuring 22.00 mm and shorter. Normal values ranged from 2.50 to 3.50 mm for ACD (mean=3.00 mm), from 4.40 to 5.44 mm for LT (mean=4.92 mm), and from 42.50 to 44.82 dioptres for Ks (mean=43.66 dioptres).

Conclusion

Measurements of the biometric mean values compared favourably with published data. The e-norms methodology assisted in establishing a biometric reference range. Furthermore, it allowed us to cluster patients into groups based on AL differences.

Classification for treatment urgency for the microphthalmia/anophthalmia spectrum using clinical and biometrical characteristics

PURPOSE

Current clinical classifications do not distinguish between the severity of the MICrophthalmia/Anophthalmia (MICA) spectrum with regard to treatment urgency. We aim to provide parameters for distinguishing mild, moderate and severe MICA using clinical and biometrical characteristics.

METHODS

We performed a single-centre, cross-sectional analysis of prospective cohort of 58 MICA children from September 2013 to February 2018 seen at the Amsterdam University Medical Center, The Netherlands. All patients with a visible underdeveloped globe were included. We performed full ophthalmic evaluation including horizontal palpebral fissure length, axial length by ultrasound and/or MRI measurements, paediatric and genetic evaluation. Cases were subdivided based on clinical characteristics. Biometrical data were used to calculate the relative axial length (rAL) and the relative horizontal palpebral fissure length (rHPF) compared with the healthy contralateral eye for unilateral cases.

RESULTS

In previously untreated patients, a strong correlation exists between rAL and rHPF, distinguishing between severe, moderate and mild subjects using rAL of 0-45%, 45-75% and 75%-100%, respectively. Clinical subgroups were randomly dispersed throughout the scatterplot.

CONCLUSION

Current classifications lack clinical implications for MICA patients. We suggest measuring eyelid length and axial length to classify the severity and determine treatment strategy. The 'severe' group has obvious asymmetry and abnormal socket configuration for which therapy should quickly be initiated; the 'moderately' affected group has normal socket anatomy with a microphthalmic eye with disturbing asymmetry for which treatment should be initiated within months of development; the 'mild' group has a slightly smaller axial length or less obvious eyelid asymmetry for which reconstructive correction is possible, but expansive conformer treatment is unnecessary.

Patient-reported outcome measures in presbyopia: a literature review

Presbyopia is the age-related loss of near-distance focusing ability. The aim of this study was to identify patient-reported outcome measures (PROMs) used in clinical trials and quality-of-life studies conducted in individuals with presbyopia and to assess their suitability for use in individuals with phakic presbyopia. Literature searches were performed in Medline and Embase up until October 2017. Specific search terms were used to identify presbyopia studies that included a PROM. All clinical trials with PROM-supported endpoints in presbyopia were identified on ClinicalTrials.gov. Further searches were conducted to retrieve articles documenting the development and psychometric evaluation of the PROMs identified. A total of 703 records were identified; 120 were selected for full-text review. Twenty-one clinical trials employed PROMs to support a primary or secondary endpoint. In total, 13 PROMs were identified; a further 23 publications pertaining to the development and validation of these measures were retrieved. Most PROMs were developed prior to release of the Food and Drug Administration (FDA) 2009 patient-reported outcome guidance and did not satisfy regulatory standards. The Near Activity Visual Questionnaire (NAVQ) was identified as the most appropriate for assessing near-vision functioning in presbyopia. While the NAVQ was developed in line with the FDA guidance, the items do not reflect changes in technology that have occurred since the questionnaire was developed in 2008 (eg, the increase in smartphone use), and the measure was not validated in a purely phakic presbyopia sample. Further research is ongoing to refine the NAVQ to support trial endpoints related to changes in near-vision functioning associated with phakic presbyopia.

Paediatric ocular adnexal lymphoma: a population-based analysis

Objective

To investigate the incidence, clinicopathological characteristics and survival of ocular adnexal lymphoma (OAL) in the paediatric population.

Methods and analysis

In this retrospective case series, the Surveillance, Epidemiology and End Results database was accessed to identify individuals with OAL ≤18 years of age, diagnosed between 1973 and 2015. OAL located in the eyelid, conjunctiva, lacrimal apparatus and orbit were included. Main outcome measures were the age-adjusted incidence rates (IRs) per 1 000 000 population at risk (calculated for the period 2000–2015) and descriptive statistics of demographic and clinicopathological features.

Results

The IR of paediatric OAL was 0.12 (95% CI 0.08 to 0.16) per 1 000 000. Males (0.15; 95% CI 0.10 to 0.22) and blacks (0.24; 95% CI 0.13 to 0.42) had a higher tendency for OAL development. A total of 55 tumours in 54 children were identified. The majority were localised (78.4%), conjunctival (49.1%) lymphomas. Extranodal marginal zone lymphoma (EMZL, 45.5%, n=25) was the most frequent subtype, followed by diffuse large B-cell lymphoma (DLBCL, 9.1%, n=5), B lymphoblastic lymphoma (7.3%, n=4), follicular lymphoma (5.5%, n=3), Burkitt lymphoma (5.5%, n=3), anaplastic large cell lymphoma (ALCL, 3.6%, n=2), small lymphocytic lymphoma (1.8%, n=1), diffuse large B-cell lymphoma, immunoblastic (1.8%, n=1) and panniculitis-like T-cell lymphoma (1.8%, n=1). Localised, low-grade, conjunctival lymphomas were frequently treated with complete excision with or without radiation, while high-grade and distant tumours usually received chemotherapy. Only 29.1% of paediatric OAL cases were treated with radiation. Three out of five (60%) patients with DLBCL died of lymphoma at a median follow-up of 21 (range 10–86) months, and 1 out of 2 (50%) patients with ALCL died of lymphoma at 23 months from diagnosis.

Conclusion

OAL in the paediatric population is rare. The majority of OAL are EMZL and are characterised by excellent prognosis. The histological subtype was found to be the main predictor of outcome with cancer-specific deaths observed in patients with DLBCL and ALCL.

Association of alcohol intake with incidence and progression of diabetic retinopathy

PURPOSE

We examined the longitudinal association of baseline alcohol intake and frequency with the 6-year incidence and progression of diabetic retinopathy (DR) in a population-based cohort of Singaporean Indians.

METHODS

We included 656 participants with diabetes mellitus, gradable retinal photographs from baseline (2007-2009) and follow-up (2013-2015) examinations, information on alcohol intake and other relevant data from the Singapore Indian Eye Study were included. Incident DR was defined using the Modified Airlie House Classification as no DR at baseline and at least minimal non-proliferative DR at follow-up; and DR progression as at least a one-step worsening in DR at follow-up from minimal or worse status at baseline, excluding those with proliferative DR.

RESULTS

The mean age (SD) of our participants (n=656) was 58.8 (9.2) years, and 54.4% were male. At follow-up, 82 of 510 (16%) participants developed DR, and 45 of 146 (30.8%) had DR progression. 65 (12.7%) and 28 (19.1%) participants consumed alcohol in incident DR and progression categories, respectively. In multivariable analyses, those who consumed alcohol had nearly two-thirds reduced odds of incident DR (OR (95% CI): 0.36 (0.13 to 0.98)) compared with those who did not. Participants with infrequent consumption of alcohol also had a reduction in odds of incident DR (0.17 (0.04 to 0.69)), compared with non-drinkers. No association was found between alcohol consumption and DR progression.

CONCLUSIONS AND RELEVANCE

In our longitudinal population of Singapore Indians, baseline alcohol intake, particularly infrequent consumption, was associated with lower risk of developing DR, compared with non-drinkers, in line with previous cross-sectional findings.

Factors influencing the decision-making of carers of children with bilateral cataract in Nepal

Objectives

Two hundred thousand children worldwide are blind from cataract. Late presentation for surgery resulting in poor visual outcomes is a problem globally. We aimed to explore the reasons why children are not brought earlier for surgery in Nepal.

Methods and analysis

Mixed-method study of carers of children with bilateral cataract attending a large non-government eye hospital were administered a proforma. A random sample took part in semistructured interviews and focus group discussions.

Results

Carers of 102 children completed proformas; 10 interviews and 2 focus group discussions were held. 80.4% were Indian, 35.3% of children were female, and their mean age was 58 months (range 4 months to 10 years). Median delay in time between the carer first noticing a problem to presentation was 182 days IQR (60.8–364.8). This was significantly longer for girls (median 304 IQR (91.2–1094.4)) than boys (median 121.6 IQR (30.4–364.8); p=0.02). Cost to access care was a problem for 42 (41.2%) carers. 13 (12.8%) participants were not aware of treatment and 12 (11.8%) were aware but did not seek treatment. The community influenced carer’s health-seeking behaviour. Cataract was sometimes described as ‘phula’, meaning something white seen on the eye.

Conclusion

Fewer girls presented for surgery, and they also had a significantly longer delay to presentation than boys. Carers are influenced by factors at family, community and socio-organisational levels. Approaches to increase timely access, particularly by girls, are required, such as health education using the term phula, which is widely understood.

Normative patterns and factors associated with presbyopia progression in a multiethnic Asian population: the Singapore Epidemiology of Eye Diseases Study

BACKGROUND/AIM

To investigate normative patterns and factors associated with presbyopia progression in a multiethnic Asian population.

METHODS

Malay, Indian and Chinese participants aged 40-80 years who had baseline and 6-year follow-up examinations with subjective refraction data were recruited from the Singapore Epidemiology of Eye Diseases Study. Presbyopia progression was defined as an increase in near addition power of ≥+0.50 dioptre (D) from baseline to follow-up visit. Modified Poisson regression analyses were used to determine baseline factors associated with presbyopia progression.

RESULTS

From the eligible 3974 eyes, 2608 eyes were included for final analysis after excluding eyes with a history of cataract surgery (929 eyes) and best-corrected distance visual acuity worse than 20/40 (342 eyes). Overall the mean near addition power change over 6 years was +0.25 D; Malays showed greater change (+0.37 D) compared with Indians (+0.23 D) and Chinese (+0.16 D). After adjusting for baseline age, gender, body mass index, hypertension, cataract, refractive error and daily hours of reading and writing, Malays were more likely to have presbyopia progression compared with Chinese (RR (relative risk)=1.67; 95% CI 1.43 to 1.95; p<0.001) and Indians (RR=1.45; 95% CI 1.25 to 1.68; p<0.001). Individuals aged 60-69 years (RR=0.77; p=0.006) and ≥70 years (RR=0.51; p<0.001) were less likely to progress in presbyopia compared with those aged 40-49.

CONCLUSION

In this Asian population, the near addition power change over 6 years was lower than the current near addition prescription guidelines (+0.25 D vs +0.60 D). Our findings may help update near addition prescription guidelines that can be more tailored to Asians.

Heritability of pachymetric indices using Pentacam Scheimflug imaging

AIM

To investigate the heritability of corneal thickness at the apex, entrance pupil centre, thinnest point, pachymetric progression index (PPI) and maximum Ambrósio relational thickness (ART_max) using Pentacam.

METHODS

The present cross-sectional and population-based study was conducted in two rural districts that were selected randomly. Individuals 5 years and older and data from households where one of the parents and at least one child participated in the study were considered for this analysis. All subjects were examined for visual acuity, refraction, biomicroscopy and, finally, Pentacam imaging. The heritability estimate was used to calculate familial aggregation of pachymetric indices.

RESULTS

Of the 3851 selected individuals, 3314 participated in the study. After applying the exclusion criteria, a total of 1383 individuals from 382 households were included in the analysis; of these, 754 (54.52%) were female. The mean age of the subjects was 37.23±19.35 years (from 6 to 93 years). The highest heritability was observed for corneal thickness at the apex (85%), and the lowest was for ART_max (27.62%). The heritability of other studied parameters, including corneal thickness at the entrance pupil centre, thinnest point and average PPI, was 82.0%, 77.0% and 31.49%, respectively.

CONCLUSION

The high heritability of the mentioned pachymetric parameters confirms the high correlation between these phenotypes and genetic factors and calls for genetic and molecular research to find related genes and to understand the aetiology of associated diseases, especially glaucoma and keratoconus.

Singapore Chinese Eye Study: key findings from baseline examination and the rationale, methodology of the 6-year follow-up series

BACKGROUND/AIMS

In order to address the eye care needs of the increasing numbers of elderly Chinese globally, there is a need for comprehensive understanding on the longitudinal trends of age-related eye diseases among Chinese. We herein report the key findings from the baseline Singapore Chinese Eye Study (SCES-1), and describe the rationale and methodology of the 6-year follow-up study (SCES-2).

METHODS

3353 Chinese adults who participated in the baseline SCES-1 (2009-2011) were invited for the 6-year follow-up SCES-2 (2015-2017). Examination procedures for SCES-2 included standardised ocular, systemic examinations and questionnaires identical to SCES-1. SCES-2 further included new examinations such as optical coherence tomography angiography, and questionnaires to evaluate health impact and economic burden of eye diseases.

RESULTS

In SCES-1, the age-adjusted prevalence of best-corrected low vision (VA<6/12, better-seeing eye) and blindness (VA<6/60, better-seeing eye) were 3.4% and 0.2%, respectively. The prevalence rates for glaucoma, age related macular degeneration, and diabetic retinopathy (among diabetics) were 3.2%, 6.8%, 26.2%, respectively. Of the 3033 eligible individuals from SCES-1, 2661 participated in SCES-2 (response rate=87.7%). Comparing with those who did not attend SCES-2, those attended were younger, had higher SES (all p<0.001), but less likely to be a current smoker, to have diabetes, hypertension, hyperlipidaemia (all p≤0.025).

CONCLUSIONS

Building on SCES-1, SCES-2 will be one of the few longitudinal population-based eye studies to report incidence, progression, and risk factors of major age-related eye diseases. Findings from this cohort may offer new insights, and provide useful reference information for other Chinese populations elsewhere.

Three presentations of CNS disease in patients with intraocular retinoblastoma at a tertiary medical center in the United States

BACKGROUND

Patients with intraocular retinoblastoma who present with central nervous (CNS) disease at diagnosis is very rare in developed countries.

METHODS

Herein, we report a review of patients with intraocular retinoblastoma diagnosed with concurrent CNS disease in the United States between January 2011 and June 2013.

RESULTS

Three patients were identified in this review. The first case is a 2-year old male who presented with unilateral Group E retinoblastoma, optic nerve infiltration to the orbital apex, and a suprasellar mass. The second case is a 5-month old female with bilateral retinoblastoma, who had no optic nerve invasion, but demonstrated a temporal lobe lesion that was biopsy-proven to be metastatic retinoblastoma. The third case is a 10-month old girl with bilateral retinoblastoma who presented with a sellar mass and no evidence of optic nerve invasion in the enucleated Group E eye.

CONCLUSIONS

Although rare in developed countries, patients with intraocular retinoblastoma can present with a spectrum of CNS findings at the time of diagnosis. Magnetic resonance imaging of the brain and orbits is a critical component of the staging evaluation.