Ethnic Differences in the Rates of Posterior Capsule Rupture and Long-Term Sequelae in Phacoemulsification Cataract Surgery.

Purpose The purpose of this study is to investigate the rates of posterior capsular rupture (PCR) and its sequelae during phacoemulsification across different ethnicities. Methods This is a retrospective cohort study of all consecutive phacoemulsification cases complicated by PCR that met the inclusion criteria over a four-year period at a single tertiary eye centre in the United Kingdom (UK). Results PCR occurred in 0.85% of cases overall (157/18,481). PCR rates were 1.8% (26/1485), 1.2% (51/4350), and 0.7% (75/10,927) in African-Caribbean, Indian subcontinent, and Caucasian patients, respectively (p < 0.001). Mean final corrected distance visual acuity improved (p < 0.05) in all ethnic groups (0.40 ± 0.57 logMAR) compared to pre-op (0.78 ± 0.61 logMAR). Post-operative cystoid macular oedema and unstable intraocular pressure rates following PCR did not statistically differ amongst ethnicities (p = 0.37 and p = 0.75, respectively). However, post-operative uveitis rates significantly differed at 11.5%, 15.7%, and 1.3% amongst the three ethnic groups, respectively (p = 0.01). Conclusion This is the first study to highlight a possible link between patient ethnicity and the risk of PCR during phacoemulsification cataract surgery. We observed significantly greater numbers of PCR cases amongst certain ethnic groups (highest in African-Caribbean eyes, then Indian subcontinental eyes, and lowest in Caucasian eyes) within the same multi-cultural urban population. Ethnicity may therefore be a contributing factor for PCR and should potentially be taken into consideration during preoperative risk stratification.

Evaluating the quality and readability of online information on keratoconus treatment.

OBJECTIVE: This study aims to evaluate the quality and readability of online resources on keratoconus treatment. METHODS: A Google.com search was conducted on August 9, 2020; 32 web sites were selected for analysis. Popularity was assessed by Google and Alexa rank. The quality of web sites was analyzed using the quality criteria for consumer health information (DISCERN) tool, the Journal of the American Medical Association (JAMA) benchmark, and the Health On the Net Code of Conduct Certification (HONcode). The readability of the web sites was assessed using the Fleschwebr hea Reading Ease, the Automated Readability Index, and the Fleschted Readability RESULTS: The JAMA benchmark scores, unlike the DISCERN scores, were correlated with the Google and Alexa rank. One web site (3.1%) met all the JAMA benchmark criteria, and 3 (9.3%) others had HONcode certification. The median DISCERN score was 33 (range, 29.6-43.1; maximum possible, 80). Rnib.org.uk scored the highest at 57 (71.0%). The mean Flesch-Kincaid Reading Ease score (52.9 ± 7.1) corresponded to uk" n DIdifficult to read." Thirty-one web sites (96.8%) had a Flesch-Kincaid Grade higher than the American Medical Association recommendation of sixth grade level. The median Automated Readability Index score was 7 (range, 6.2-7.3). CONCLUSION: The majority of online information currently available on keratoconus treatment is complex and highly variable. Rnib.org.uk is the best currently available source. Clinicians should inform patients on how to assess the credibility of online information and recommend suitable information sources.

High Astigmatism After Conventional Diameter Deep Anterior Lamellar Keratoplasty in Keratoconus Can Be Successfully Managed With Repeat Wide Diameter Deep Anterior Lamellar Keratoplasty.

PURPOSE: The aim of this study was to describe a new surgical technique to replace a conventional diameter (≤8 mm) deep anterior lamellar keratoplasty (DALK) graft with associated high astigmatism refractory to corneal-based astigmatic procedure/intolerance to contact lenses with a larger diameter (≥9 mm) DALK graft to improve best spectacle-corrected visual acuity (BSCVA). METHODS: Two eyes from 2 keratoconic patients at Southend University Hospital between December 2019 and June 2021 with a minimum follow-up of 17 months were evaluated. The primary outcome of interest was Snellen BSCVA with a secondary outcome of topographic cylinder. RESULTS: Patient 1 had undergone initial 8 mm diameter DALK, with residual keratometric astigmatism of nearly 12 diopters (D) postoperatively despite numerous astigmatic interventions, with a BSCVA of 6/60, before undergoing 9 mm diameter repeat modified DALK. After suture removal and subsequent in-the-wound blunt manual relaxing incisions, the patient had a final keratometric astigmatism of 3.5 D, manifest refraction of plano/-3.50 × 175, and a BSCVA of 6/9. Patient 2 had undergone initial 7.75 mm diameter DALK, with residual keratometric astigmatism of 10.5 D with a BSCVA of counting fingers. The patient underwent 9 mm repeat modified DALK with final residual keratometric astigmatism of 3.1 D after suture removal, manifest refraction of -1.00/-2.75 × 25, and BSCVA of 6/9. CONCLUSIONS: Wide diameter DALK (>9 mm) is effective in the management of conventional diameter DALK (≤8 mm) associated high astigmatism in keratoconus. Creation of a peripheral posterior stromal shoulder also allows safe further titration of residual astigmatism if needed.

"Comparing outcomes of advanced nurse practitioners to ophthalmologists performing posterior YAG capsulotomy, a six-year study of 6308 eyes".

PURPOSE: To primarily report the baseline characteristics and visual acuity (VA) outcomes of advanced nurse practitioners (ANP) compared to ophthalmologists following YAG posterior capsulotomy (YAGPC). We secondarily looked to characterise the risk factors that lead to a repeated YAGPC. METHOD: Retrospective consecutive case series of 6,308 eyes attending the Birmingham and Midlands Eye Centre. RESULTS: ANPs performed 33.1% of YAGPC compared to 66.9% ophthalmologists. Compared to ophthalmologists, ANPs performed YAGPC in lower proportion of patients with ocular co-morbidities (p < 0.001) and had lower proportion of patients requiring further YAGPC compared to ophthalmologists (p < 0.001). Median pre, post-operative and LogMAR gain in VA of 0.48 (IQR 0.30-0.78), 0.18 (IQR 0.10-0.40) and 0.30 (0.08-0.48) LogMAR units, respectively. Multivariate regression showed that ANPs had a significantly lower rate of repeat YAGPC compared to ophthalmologists even when adjusting for age, ethnicity, training grade and ocular co-morbidities. No difference in visual outcomes was found between operator grade and ethnicity on multivariate analysis. CONCLUSION: YAGPC leads to excellent visual outcomes. ANPs can deliver safe and effective YAGPC.

Conjunctival transcriptomics in ocular mucous membrane pemphigoid.

PURPOSE: Ocular Mucous Membrane Pemphigoid (OcMMP) is an orphan disease characterized by chronic autoimmune-driven conjunctival inflammation leading to progressive scarring, debilitating symptoms, and blinding sequelae. This feasibility study aims to demonstrate conjunctival genetic transcriptomic analyses as a putative tool for interrogation of pathogenic signaling pathways in OcMMP. METHODS: Conjunctival RNA profiling using the NanoString nCounter Human Fibrosis panel was undertaken on RNA extracted from conjunctival swabs obtained from 6 MMP patients (8 eyes; 4 M/2F; median age 78 [range 64-84] years); and 8 age-matched control participants (15 eyes; 3 M/5F; median age 69.5 [range 69-88] years). Data from 770 genes were analyzed with ROSALIND HyperScale architecture and stratified according to the level of clinically visible bulbar conjunctival inflammation. Normalization, fold-changes (≥+1.5-fold or ≤ -1.5-fold) and p-values adjustment (<0.05) using the Benjamini-Hochberg method were calculated. RESULTS: 93 differentially expressed genes (DEGs) were observed between OcMMP versus controls of which 48 were upregulated, and 45 downregulated. The top 4 upregulated DEGs represented fibrosis (COL3A1, COL1A1, FN1 and THBS1) while the key under-expressed genes (SCIN, HMGS2, XCL1/2) were indicative of ocular surface failure (goblet cell loss, keratinization, vulnerability to secondary infections). Forty-four pathways had a global significance score ≥2, the most significant being those related to extracellular matrix (ECM) remodeling, synthesis, and degradation. These pathways were accentuated in eyes with visible inflammation. CONCLUSIONS: NanoString methodology acquired via a simple conjunctival swab identifies profibrotic genes in OcMMP group and differentiates inflamed eyes. Longitudinal sampling and following investigative intervention will further mechanistic insight and development of novel biomarkers to monitor disease progression.

Intravitreal dexamethasone to manage post endothelial keratoplasty cystoid macular oedema refractory to topical therapy.

BACKGROUND/OBJECTIVES: To describe the visual and clinical outcomes of patients with post endothelial keratoplasty (EK) cystoid macular oedema (CMO) refractory to topical treatment with intravitreal sustained-release dexamethasone implant (Ozurdex). SUBJECTS/METHODS: 131 eyes from 111 patients undergoing solitary or combined EK (52 DSAEK (40.0%) and 79 DMEK (60.0%)) at Southend University Hospital between January 2020 and February 2022 with a minimum follow-up of 6 months were evaluated. Patients suspected of having CMO underwent spectral-domain macular optical coherence tomography (SD-OCT) Patients with diabetes were not included in this series. RESULTS: CMO was identified in 5.3% (n = 7) of cases, with 2 of these patients responding to topical corticosteroid treatment. The remaining 5 patients underwent intravitreal dexamethasone implant, with 1 patient requiring repeat implant due to CMO recurrence. All presented within 2 months postoperatively. 4 out of 5 eyes treated with intravitreal dexamethasone achieved a Snellen BCVA ≤6/9.5. 1 patient had an uncontrolled rise in intraocular pressure (IOP) despite maximal medical treatment requiring an urgent PreserFlo Ab-Externo MicroShunt. CONCLUSIONS: The use of intravitreal sustained-release dexamethasone implant in the management of post EK CMO refractory to topical therapy is effective and safe in most cases, but patients should be monitored and treated promptly for any secondary IOP response.

Evaluating patient-reported outcome measures (PROMs) for future clinical trials in adult patients with optic neuritis.

OBJECTIVE: To search for and critically appraise the psychometric quality of patient-reported outcome measures (PROMs) developed or validated in optic neuritis, in order to support high-quality research and care. METHODS: We systematically searched MEDLINE(Ovid), Embase(Ovid), PsycINFO(Ovid) and CINAHLPlus(EBSCO), and additional grey literature to November 2021, to identify PROM development or validation studies applicable to optic neuritis associated with any systemic or neurologic disease in adults. We included instruments developed using classic test theory or Rasch analysis approaches. We used established quality criteria to assess content development, validity, reliability, and responsiveness, grading multiple domains from A (high quality) to C (low quality). RESULTS: From 3142 screened abstracts we identified five PROM instruments potentially applicable to optic neuritis: three differing versions of the National Eye Institute (NEI)-Visual Function Questionnaire (VFQ): the 51-item VFQ; the 25-item VFQ and a 10-item neuro-ophthalmology supplement; and the Impact of Visual Impairment Scale (IVIS), a constituent of the Multiple Sclerosis Quality of Life Inventory (MSQLI) handbook, derived from the Functional Assessment of Multiple Sclerosis (FAMS). Psychometric appraisal revealed the NEI-VFQ-51 and 10-item neuro module had some relevant content development but weak psychometric development, and the FAMS had stronger psychometric development using Rasch Analysis, but was only somewhat relevant to optic neuritis. We identified no content or psychometric development for IVIS. CONCLUSION: There is unmet need for a PROM with strong content and psychometric development applicable to optic neuritis for use in virtual care pathways and clinical trials to support drug marketing authorisation.

Treatments for Ocular Diseases in Pregnancy and Breastfeeding: A Narrative Review.

Pregnancy is a medical condition in which the physiological changes in the maternal body and the potential impact on the developing fetus require a cautious approach in terms of drug administration. Individual treatment, a thorough assessment of the extent of the disease, and a broad knowledge of the therapeutic options and different routes of administration of ophthalmic drugs are essential to ensure the best possible results while minimizing risks. Although there are currently several routes of administration of drugs for the treatment of eye diseases, even with topical administration, there is a certain amount of systemic absorption that must be taken into account. Despite continuous developments and advances in ophthalmic drugs, no updated data are available on their safety profile in these contexts. The purpose of this review is both to summarize the current information on the safety of ophthalmic treatments during pregnancy and lactation and to provide a practical guide to the ophthalmologist for the treatment of eye diseases while minimizing harm to the developing fetus and addressing maternal health needs.

Deposition keratopathy.

Material can be deposited in the cornea as a result of a wide range of systemic and ophthalmic diseases, as well as local and systemic therapies. Causes include local infection or trauma, systemic malignancy, a wide range of medications and a host of genetic and metabolic diseases. Some of these can be acutely life threatening, so generalists caring for both children and adults should have a basic awareness of the pattern and distribution of corneal deposits to facilitate timely diagnosis, investigation, management or onward referral to avoid significant morbidity or mortality. This article outlines causes of corneal deposits found in patients presenting to primary care, ophthalmic clinics or encountered on the wards to help generalists avoid missing serious pathology. It also provides insight into the natural history of underlying causative conditions and their possible treatments.

Comparing the outcomes of YAG laser anterior capsulotomies performed by an advanced nurse practitioner to ophthalmologists in the management of anterior capsular contraction syndrome.

BACKGROUND: Anterior capsular contraction syndrome (ACCS) describes the progressive fibrotic phimosis of the anterior capsular bag that usually occurs a few months after cataract surgery. YAG laser anterior capsulotomy (YAGAC) is the most common treatment option due to the low-risk profile of this intervention. PURPOSE: In this series, we evaluated the outcomes of an advanced nurse practitioner (ANP) in conducting this laser intervention, comparing the results with those of ophthalmologists. METHODOLOGY: Our study represents a single-centre, retrospective, continuous case series of 108 eyes that underwent YAGAC due to ACCS between January 2017 and July 2020 at the Birmingham and Midland Eye Centre, the second largest tertiary referral centre in the United Kingdom. RESULTS: The groups treated by ANPs and ophthalmologists were similar in respect to age, gender, and laterality of the laser procedure. Eyes treated by ophthalmologists had significantly more ocular comorbidities (p < .001), the most common of which was glaucoma. Although the complication rate was higher in the ophthalmologist group, it did not reach statistical significance. However, there was a trend toward significance in the retreatment rate, with 8.6% (7/81) of eyes lasered by ophthalmologists requiring further YAGAC, and no repeat procedure was needed in the ANP group. CONCLUSIONS: YAGAC leads to good visual outcomes and a low complication rate in both ophthalmologist and ANP groups. IMPLICATIONS: Advanced nurse practitioners can deliver results that are comparable with those of experienced ophthalmologists.

Evaluating patient-reported outcome measures (PROMs) for clinical trials and clinical practice in adult patients with uveitis or scleritis: a systematic review.

Patient reported outcome measures (PROMs) capture impact of disease and treatment on quality of life, and have an emerging role in clinical trial outcome measurement. This study included a systematic review and quality appraisal of PROMs developed or validated for use in adults with uveitis or scleritis. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and grey literature sources, to 5 November 2021. We used established quality criteria to grade each PROM instrument in multiple domains from A (high quality) to C (low quality), and assessed content development, validity, reliability and responsiveness. For instruments developed using classic test theory-based psychometric approaches, we assessed acceptability, item targeting and internal consistency. For instruments developed using Item Response Theory (IRT) (e.g. Rasch analysis), we assessed response categories, dimensionality, measurement precision, item fit statistics, differential item functioning and targeting. We identified and appraised four instruments applicable to certain uveitis types, but none for scleritis. Specifically, the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ), a 3-part PROM for Birdshot retinochoroiditis (Birdshot Disease & Medication Symptoms Questionnaire [BD&MSQ], the quality of life (QoL) impact of Birdshot Chorioretinopathy [QoL BCR], and the QoL impact of BCR medication [QoL Meds], the Kings Sarcoidosis Questionnaire (KSQ), and a PROM for cytomegalovirus retinitis. These instruments had limited coverage for these heterogeneous conditions, with a focus on very rare subtypes. Psychometric appraisal revealed considerable variability between instruments, limited content development, and only one developed using Item Response Theory. In conclusion, there are few validated PROMs for patients with uveitis and none for scleritis, and existing instruments have suboptimal psychometric performance. We articulate why we do not recommend their inclusion as clinical trial outcome measures for drug licensing purposes, and highlight an unmet need for PROMs applicable to uveitis and scleritis.

Transient facial nerve palsy following dental local anaesthesia.

Facial nerve palsy is a rare but known complication of dental local anaesthesia and may be underreported. We describe a case of a transient facial nerve palsy following the administration of an inferior alveolar nerve block and discuss the immediate practical management. Knowing the likely transient nature of this complication means the patient can be reassured and unnecessary referral avoided. While the blink reflex is inhibited, steps are needed in order to protect the cornea and prevent secondary infection and scarring.

Acquired nystagmus.

Nystagmus is the repetitive to and fro movement of the eyes, which may be physiological or pathological. The movements can be horizontal, vertical, torsional or a combination of these movements. It starts by a slow movement of the eye away from the visual target. The second movement brings the eye back to the visual target. If this second movement is quick, the nystagmus is called jerk nystagmus. If the second movement is slow, the nystagmus is said to be pendular. Maintaining steady gaze is dependent upon visual fixation, the vestibulo-ocular reflex and the gaze-holding neural integrator system. Pathological nystagmus typically presents with the symptom of oscillopsia, which is the illusory movement of the surrounding environment. Nystagmus that develops outside of early infancy is termed acquired nystagmus. There may be serious underlying pathology that will require further investigation and management. This article reviews the terminology, pathophysiology, causes and treatment of acquired nystagmus.

Instrument-based Tests for Measuring Anterior Chamber Cells in Uveitis: A Systematic Review.

PURPOSE: New instrument-based techniques for anterior chamber (AC) cell counting can offer automation and objectivity above clinician assessment. This review aims to identify such instruments and its correlation with clinician estimates. METHODS: Using standard systematic review methodology, we identified and tabulated the outcomes of studies reporting reliability and correlation between instrument-based measurements and clinician AC cell grading. RESULTS: From 3470 studies, 6 reported correlation between an instrument-based AC cell count to clinician grading. The two instruments were optical coherence tomography (OCT) and laser flare-cell photometry (LFCP). Correlation between clinician grading and LFCP was 0.66-0.87 and 0.06-0.97 between clinician grading and OCT. OCT volume scans demonstrated correlation between 0.75 and 0.78. Line scans in the middle AC demonstrated higher correlation (0.73-0.97) than in the inferior AC (0.06-0.56). CONCLUSION: AC cell count by OCT and LFP can achieve high levels of correlation with clinician grading, whilst offering additional advantages of speed, automation, and objectivity.