Visual supplementation is an effective tool in cataract surgery counselling by eye-care practitioners.

BACKGROUND: Informed consent constitutes an important aspect of eye care. However, patients often experience difficulties understanding and retaining information presented to them during consultations. This study investigates the efficacy of pictorial aids in supplementing preoperative counselling of patients undergoing cataract surgery. METHODS: Patients attending routine pre-cataract surgery counselling were randomized to receive either a standard verbal consultation (control) or a verbal consultation with a digitalized pictorial aid illustrating key surgical steps (intervention). Patients were assessed after the consultation on their knowledge, satisfaction, anxiety and preparedness using an anonymous questionnaire. RESULTS: Seventy-six patients were recruited and randomized into the control and intervention groups. The intervention group attained better Knowledge Scores (control: 5 [2-6] vs. intervention: 6 [6]), and more patients "strongly agreed" that they were more prepared (control: 78.9% vs. intervention: 97.4%, P=0.028). A higher proportion of patients in the control group either "disagreed" or "neither disagree nor agreed (neutral)" that they were less worried (control: 15.8% vs. intervention: 0.0%, Fisher's Exact Test P=0.025). Although the consultation duration was shorter in the intervention group (21±4mins vs. 27±6mins, P<0.001), the use of digital pictorial aids during consultation resulted in more effective counselling with increased patient knowledge, easier decision-making process and reduced patient anxiety. CONCLUSION: Pictorial aids add to the repository of tools available to eye-care practitioners and are low-cost, easy to implement, and can effectively augment existing preoperative counselling processes to ensure accurate and effective preoperative counselling of patients.

The structural and functional corneal reinnervation mechanism at different regions after LASIK-an in vivo confocal microscopy study.

PURPOSE: To determine the recovery of structural and functional corneal sensory nerves within the LASIK flap in order to provide insight to more proximal corneal reinnervation and symptoms post-LASIK. METHODS: Twenty participants underwent femtosecond LASIK with a superior flap hinge. Ocular Comfort Index in Chinese (OCI-C), Cochet-Bonnet esthesiometry, and in vivo confocal microscopy were conducted before surgery and 1 week, 1-, 3-, and 6-months post-LASIK to measure symptoms, corneal sensitivity, nerve fiber density, width, and the number of interconnections within the flap (central and mid-temporal regions), and next to the superior flap hinge. Linear mixed models were used to compare differences between corneal regions at each time point post-LASIK and changes over time post-LASIK. Spearman's correlation tests were used to examine the associations between variables post-LASIK. RESULTS: The least reduction in sensitivity (P < 0.03) and in nerve fiber density (P < 0.02) was found near the flap hinge compared to other regions, but no regional differences were found in nerve fiber width and interconnections. Nerve fiber density and the number of interconnections at all regions within the flap recovered over time (P < 0.02). The recovery of corneal sensitivity and nerve fiber width was only seen at the central and temporal regions (P < 0.04). No association was found between sensitivity and nerve parameters, but a higher OCI-C score was associated with a lower nerve fiber density near the hinge (r = - 0.43, P = 0.003) over time post-LASIK. CONCLUSION: Corneal sensitivity and density are preserved in the hinge, but this preservation of the corneal nerve damage does not affect the nerve morphology.

The 2019 Joseph W. St. Geme, Jr Leadership Award Address: Ubuntu: The Power of Social Connections.

The following is an address given by the author in receipt of the Joseph W. St. Geme, Jr Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies Meeting in Baltimore, Maryland, on April 27, 2019.

Training Pediatricians to Address Health Disparities: An Innovative Residency Track Combining Global Health With Community Pediatrics and Advocacy.

PROBLEM: Pediatric residency programs have been tasked to train a workforce of pediatricians with skills in community pediatrics (CP) and advocacy, and knowledge of global child health priorities. APPROACH: In 2009, the University of Washington (UW) Seattle Children's Hospital pediatric residency program developed the Resident Education in Advocacy and Child Health (REACH) program, a combined pathway for global health (GH) and CP training. After participating in a combined curriculum, residents complete a community immersion either in Kisii, Kenya (GH) or rural Washington (CP). This approach provides an efficient use of faculty and administrative resources and delivers a sustainable and ethical strategy for inspiring pediatric residents to address child health problems at a systems level. OUTCOMES: Between 2009 and 2013, the percentage of graduating residents from the UW pediatric residency program who rated GH training as "outstanding/excellent/good" increased from 58.4% to 100%, and the percentage rating community and population health training as "outstanding/excellent/good" increased from 56% to 88.8%. Annual applicant surveys in the period 2011-2014 revealed that the REACH program led a significant percentage of candidates to rank the UW pediatric residency more favorably because of its GH (37%-48%) and CP (55%-74%) training. NEXT STEPS: A mixed-methods assessment will evaluate the impact on resident confidence in core areas of community health and advocacy including collaborating with community groups, setting professional career goals, addressing underlying determinants of health during patient encounters, communicating in cross-cultural settings, and advocating for child health. A survey will assess outcomes on graduates' careers.

Can preeclampsia be considered a renal compartment syndrome? A hypothesis and analysis of the literature.

The morbidity and mortality associated with preeclampsia is staggering. The physiology of the Page kidney, a condition in which increased intrarenal pressure causes hypertension, appears to provide a unifying framework to explain the complex pathophysiology. Page kidney hypertension is renin-mediated acutely and ischemia-mediated chronically. Renal venous outflow obstruction also causes a Page kidney phenomenon, providing a hypothesis for the increased vulnerability of a subset of women who have what we are hypothesizing is a "renal compartment syndrome" due to inadequate ipsilateral collateral renal venous circulation consistent with well-known variation in normal venous anatomy. Dynamic changes in renal venous anatomy and physiology in pregnancy appear to correlate with disease onset, severity, and recurrence. Since maternal recumbent position is well known to affect renal perfusion and since chronic outflow obstruction makes women vulnerable to the ischemic/inflammatory sequelae, heightened awareness of renal compartment syndrome physiology is critical. The anatomic and physiologic insights provide immediate strategies to predict and prevent preeclampsia with straightforward, low-cost interventions that make renewed global advocacy for pregnant women a realistic goal.

Risk factors for contact lens-related microbial keratitis in Singapore.

PURPOSE: To investigate independent risk factors for contact lens-related microbial keratitis in Singapore and estimate their impact on disease load. METHODS: Cases were contact lens wearers presenting to Singapore National Eye Centre with microbial keratitis between 2008 and 2010. Community contact lens wearers were recruited as controls. All wearers completed a previously validated questionnaire describing contact lens wear history, hygiene and compliance habits, and demographics. Risk factors significant in univariate analysis (P<0.2) were evaluated in a multivariate model. RESULTS: In all, 58 cases of microbial keratitis and 152 contemporaneous controls were identified. When controlling for other variables, Chinese had a 7 × lower risk compared with other races (95% CI: 2.3-21.3, P=0.001). Those aged between 25 and 44 years were at 3 × increased risk compared with younger wearers (95% CI: 1.1-9.6, P=0.04). Occasional overnight contact lens wear (less often than one night per week) was associated with a 4 × higher risk (95% CI: 1.2-15.4, P=0.03) compared with daily use. Not washing hands before handling was associated with a 13 × increased risk (95% CI: 1.9-84.8, P=0.008). Use of multipurpose solution A carried a 16 × higher risk compared with hydrogen peroxide (95% CI: 1.5-174.0, P=0.02). The combined PAR% for modifiable risk factors (occasional overnight wear, not washing of hands, and MPS A) was 82%. CONCLUSIONS: Consistent with previous findings, independent risk factors for contact lens-related microbial keratitis include poor hand hygiene, occasional overnight wear, and type of lens care solution. Prolonged overnight or extended contact lens use was infrequent in this population.

An agenda for children for the 113th Congress: recommendations from the pediatric academic societies.

The 113th Congress of the United States begins in January 2013. With each new Congress, there are many changes, not only in the faces of the newly elected, but also in the membership of committees and the staff serving the members. As agendas for the session are set, there is a resurgence of conflicting priorities. In the past, when these conflicts were resolved, children were rarely at the top of the list. Given the numerous pressing national issues, both domestic and foreign, the same trend will likely occur.

Contact lens-related microbial keratitis: how have epidemiology and genetics helped us with pathogenesis and prophylaxis.

Contact lens wear is a common predisposing factor in microbial keratitis and is one of the two preventable risk factors for corneal infection in a working age population. Our understanding of the prevention and prophylaxis of contact lens-related corneal infection is informed by recent epidemiological studies describing the incidence of and risk factors for the disease, the effect of causative organism on disease severity, and an appreciation of individual immune profiles in susceptibility to and severity of the disease. Although contemporary contact lenses have not reduced the overall incidence of keratitis, a reduction in morbidity may be achievable through recognition of appropriate risk factors in severe disease, including avoiding delays in presenting for appropriate treatment, and attention to storage case hygiene practise. Severe keratitis is most commonly associated with an environmental causative organism, and daily disposable lenses are associated with less severe disease. Pseudomonas aeruginosa remains the commonest cause of contact lens-related corneal infection probably because of its unique virulence characteristics and ability to survive in the contact lens/storage case/ocular environment. In two recent outbreaks of contact lens-related infections, there has been a strong association demonstrated with particular contact lens solutions. Since the recall of these specific contact lens solutions, the rate of Acanthamoeba keratitis has remained above the expected baseline, indicating unidentified risk factors that may include environmental exposures. Individual differences in susceptibility to microbial keratitis may be partly explained by differences in single-nucleotide polymorphisms in certain cytokine genes, particularly those with a proven protective role in corneal infection.

Visual and non-visual factors associated with patient satisfaction and quality of life in LASIK.

PURPOSE: The aim of this study was to determine how laser in situ keratomileusis (LASIK) affects quality of life (QOL) and to identify factors that may affect satisfaction after LASIK. METHODS: A total of 104 patients with a mean age of 29±6, treated with LASIK for myopia and astigmatism, were enrolled in a prospective study. High (90%) and low (10%) contrast visual acuity (CVA) were measured under photopic and scotopic conditions before surgery and at 3 months later. A multidimensional QOL scale (Institute for Eye Research multidimensional QOL scale), which assesses psychological characteristics, personality traits, cosmesis, frequency, and tolerance to disturbing visual and ocular symptoms, and overall satisfaction with vision correction, was also used. Paired rank tests were used to compare preoperative and postoperative vision and QOL scores. Correlations and a multiple linear regression were used to describe the relationship between CVA, QOL, and satisfaction after LASIK. RESULTS: Significant postoperative changes included increased satisfaction following LASIK (P<0.001), reduced frequency of visual and ocular symptoms (P<0.001), and change in psychological characteristics (P=0.033). The change in satisfaction with LASIK can be predicted by a combination of preoperative satisfaction, postoperative frequency of disturbing visual and ocular symptoms, postoperative mean spherical equivalent, and postoperative scotopic high CVA (R (2)=0.725, P<0.05). CONCLUSIONS: Satisfaction with LASIK is related to visual function, preoperative expectations, psychological characteristics, and uncorrected CVA achieved. An increased sense of subjective well-being, adaptability, and self-efficacy was evident after LASIK. Patients reported a more optimistic attitude to life and increase perceived QOL after surgery.

Assessing the sensory function of the ocular surface: implications of use of a non-contact air jet aesthesiometer versus the Cochet-Bonnet aesthesiometer.

Assessment of corneal sensory function is commonly carried out using the Cochet-Bonnet aesthesiometer. The limitations of this instrument have lead to development of newer instruments, such as the CRCERT-Belmonte aesthesiometer, which utilise a jet of air as their stimulus. Recent work, however, has demonstrated contradictory effects on ocular surface sensitivity when measured with different types of aesthesiometer. The purpose of the present study was to compare clinical measurements of corneal sensitivity obtained with the CRCERT-Belmonte and the Cochet-Bonnet aesthesiometers and to examine their stimulus characteristics in terms of force exerted. No association was found between central corneal sensitivity measured with the two aesthesiometers in a group of normal subjects. Sensitivity was measured to be lower with the Cochet-Bonnet aesthesiometer than with the CRCERT-Belmonte. Over half of the subjects could not be assessed with the standard Cochet-Bonnet filament and 11% could not be assessed with either filament, as their corneal sensitivity was outside of the range of the instrument. In contrast, all subjects were within the stimulus range of the CRCERT-Belmonte aesthesiometer. Corneal sensitivity measurements made with the non-contact CRCERT-Belmonte aesthesiometer and the Cochet-Bonnet aesthesiometer are not comparable. Due to dissimilarities in the composition of their stimuli, and thus mode of stimulation, it is possible that the two instruments measure different aspects of the neural response. The underestimation of corneal sensitivity by the Cochet-Bonnet aesthesiometer and its inability to measure sensitivity of some subjects at all are important considerations in the assessment of sensitivity loss. Subtle changes are unlikely to be detected with this instrument, particularly at higher sensitivity levels. The Cochet-Bonnet should therefore be used with caution and the 0.08 mm diameter used as the filament of choice. Adoption of a non-contact aesthesiometer as standard for ocular sensitivity measurement should be considered. The non-contact instrument allows superior stimulus reproducibility and better control over stimulus characteristics, in addition to the ability for exploration of the response of all three types of neuro-receptors on the ocular surface.