Erratum.

[This corrects the article DOI: 10.1159/000454979.].

The use of peer optic nerve photographs for teaching direct ophthalmoscopy.

OBJECTIVE: To use a novel teaching exercise to encourage students to practice ophthalmoscopy and to measure the learning effect both subjectively and objectively. DESIGN: Comparative case series. PARTICIPANTS: One hundred thirty-one fourth-year medical students on their 1-week ophthalmology rotations with 89 in the experimental group and 42 in the control group. METHODS: Those in the experimental group had 1 eye dilated and their optic nerve photographed on the first day. The next day, these students received an unlabeled optic nerve photograph belonging to 1 of their peers (typically 8-10 per group) and were given 3 days to identify the student matching the photograph. The students in the control group were simply encouraged to practice ophthalmoscopy on each other without the use of photographs. MAIN OUTCOME MEASURES: Both objective and subjective changes from the beginning to the end of the rotation were measured and compared between the 2 groups. RESULTS: In the 89 students who used peer optic nerve photographs, 75 (84.3%) showed improvement in direct ophthalmoscopy skills over the course of the week. In contrast, only 12 (28.6%) of the 42 control students demonstrated an objective improvement (P<0.001). The subjective confidence levels likewise were more improved in the students who took part in the optic nerve photograph exercise. CONCLUSIONS: These results suggest that the task of matching an unknown optic nerve photograph to the correct eye of a peer leads to increased self-confidence and more proficient use of the direct ophthalmoscope.

An algorithm for glaucoma screening in clinical settings and its preliminary performance profile.

PURPOSE: To devise and evaluate a screening algorithm for glaucoma in clinical settings. METHODS: Screening included examination of the optic disc for vertical cupping (≥0.4) and asymmetry (≥0.15), Goldmann applanation tonometry (≥21 mmHg, adjusted or unadjusted for central corneal thickness), and automated perimetry. In the diagnostic step, retinal nerve fiber layer imaging was performed using scanning laser polarimetry. Performance of the screening protocol was assessed in an eye hospital-based program in which 124 non-physician personnel aged 40 years or above were examined. A single ophthalmologist carried out the examinations and in equivocal cases, a glaucoma subspecialist's opinion was sought. RESULTS: Glaucoma was diagnosed in six cases (prevalence 4.8%; 95% confidence interval, 0.01-0.09) of whom five were new. The likelihood of making a definite diagnosis of glaucoma for those who were screened positively was 8.5 times higher than the estimated baseline risk for the reference population; the positive predictive value of the screening protocol was 30%. Screening excluded 80% of the initial population. CONCLUSION: Application of a formal screening protocol (such as our algorithm or its equivalent) in clinical settings can be helpful in detecting new cases of glaucoma. Preliminary performance assessment of the algorithm showed its applicability and effectiveness in detecting glaucoma among subjects without any visual complaint.

Notch inhibition during corneal epithelial wound healing promotes migration.

PURPOSE: To determine the role of Notch signaling in corneal epithelial migration and wound healing. METHODS: Immunolocalization of Notch1 was performed during epithelial wound healing in vivo in mouse corneal epithelial debridement wounds and in vitro in primary human corneal epithelial cells following a linear scratch wound. The effects of Notch inhibition, using the γ-secretase inhibitor N-(N-[3,5-difluorophenacetyl]-l-alanyl)-S-phenylglycine t-butyl ester (DAPT) or following stable transfection with Notch1-short hairpin RNA (shRNA), was evaluated in a scratch assay and transwell migration assay. Likewise, in vitro adhesion, proliferation and the actin cytoskeleton was examined. The DAPT effect was also evaluated in vivo in a mouse model of corneal epithelial wound healing. RESULTS: The expression of Notch1 was reduced at the leading edge of a healing corneal epithelium both in vivo and in vitro. Notch inhibition using DAPT and using Notch1-shRNA both enhanced in vitro migration in scratch and transwell migration assays. Consistent with this increased migratory behavior, Notch inhibited cells demonstrated decreased cell-matrix adhesion and enhanced lamellipodia formation. Notch inhibition by DAPT was also found to accelerate corneal epithelial wound closure in an in vivo murine model without affecting proliferation. CONCLUSIONS: The results highlight the role of Notch in regulating corneal epithelial migration and wound healing. In particular, Notch signaling appears to decrease in the early stages of wound healing which contributes to cytoskeletal changes with subsequent augmentation of migratory behavior.

Erythropoietin levels in aqueous humor of patients with glaucoma.

PURPOSE: To compare the aqueous concentration of erythropoietin (EPO) in eyes with primary open-angle (POAG), pseudoexfoliative (PXFG), and neovascular (NVG) glaucoma with age-matched eyes with cataracts, and to correlate its concentration with other factors including age, gender, intraocular pressure (IOP), type of glaucoma, and severity of glaucoma. METHODS: In this prospective non-randomized comparative study, a total of 26 eyes with cataracts (control group) and 92 glaucomatous eyes (POAG, 40 eyes; PXFG, 26 eyes; NVG, 26 eyes) were enrolled. Aqueous samples (0.1 to 0.2 ml) were obtained during phacoemulsification, trabeculectomy, phacotrabeculectomy, or Ahmed valve glaucoma implants. The aqueous concentration of EPO was measured using an enzyme-linked immunosorbent assay. RESULTS: The mean±SEM aqueous level of EPO was statistically significantly higher in eyes with glaucoma (56.7±9.3 mIU/ml) compared to the control group (0.8±0.51 mIU/ml; p<0.001). Eyes with NVG had the highest aqueous level of EPO. Aqueous EPO concentrations remained considerably elevated even in eyes with controlled IOP in all three types of glaucoma. Eyes with PXFG displayed the greatest change in aqueous EPO concentration proportionate to the IOP level. In simple regression analysis, IOP, mean deviation, and the type of glaucoma were the factors that had a statistically significantly positive correlation with the aqueous level of EPO (p=0.011 and <0.001, respectively). Only the type of glaucoma remained statistically significant in the multiple regression analysis (adjusted R(2)=0.278). CONCLUSIONS: Compared to the control group, the aqueous humor EPO concentration is increased in eyes with POAG, PXFG, and NVG, both with and without controlled IOP. The aqueous level of EPO was more proportionate to the level of IOP in eyes with PXFG compared to eyes with POAG and NVG.

The role of demographic characteristics in the outcomes of cataract surgery and gender roles in the uptake of postoperative eye care: a hospital-based study.

PURPOSE: To explore the effect of demographic characteristics on the outcomes of cataract surgery in terms of visual acuity and patient satisfaction, and gender role in the uptake of postoperative care. METHODS: Comprehensive ocular examinations were performed on 478 subjects (558 eyes) over the age of 50 years who underwent surgery for age-related cataract at the largest eye hospital in Iran. Demographic characteristics were obtained and surgical records were reviewed. RESULTS: Male subjects had significantly better outcomes in terms of uncorrected visual acuity (UCVA) and best spectacle-corrected visual acuity (BSCVA) (mean difference 0.12 and 0.13 logMAR; p = 0.004 and p < 0.001, respectively). Women were significantly less satisfied than men (73.2% vs. 83.6%; p = 0.011). Postoperative UCVA and BSCVA were better in patients with higher levels of education (both p < 0.001). Age had an inverse association with UCVA (p = 0.004) and BSCVA (p < 0.001). Women were twice as likely to need capsulotomy (p = 0.002). Men's uptake of postoperative refractive care was 4-fold that of women's (31% vs. 7%). In multivariable analyses, age, sex, education, presence of ocular comorbidity and need for capsulotomy, spectacle prescription and other care were associated with postoperative UCVA (all p < 0.05; adjusted R(2) = 0.256). CONCLUSION: Female patients were shown to be at a clear disadvantage in cataract surgery; outcomes of the procedure and postoperative care were both poorer. Older age, lower level of education, ocular comorbidity and unmet postoperative need were also associated with a poorer outcome.

Using artificial intelligence to predict the risk for posterior capsule opacification after phacoemulsification.

PURPOSE: To apply artificial intelligence models to predict the occurrence of posterior capsule opacification (PCO) after phacoemulsification. SETTING: Farabi Eye Hospital, Tehran, Iran. DESIGN: Clinical-based cross-sectional study. METHODS: The posterior capsule status of eyes operated on for age-related cataract and the need for laser capsulotomy were determined. After a literature review, data polishing, and expert consultation, 10 input variables were selected. The QUEST algorithm was used to develop a decision tree. Three back-propagation artificial neural networks were constructed with 4, 20, and 40 neurons in 2 hidden layers and trained with the same transfer functions (log-sigmoid and linear transfer) and training protocol with randomly selected eyes. They were then tested on the remaining eyes and the networks compared for their performance. Performance indices were used to compare resultant models with the results of logistic regression analysis. RESULTS: The models were trained using 282 randomly selected eyes and then tested using 70 eyes. Laser capsulotomy for clinically significant PCO was indicated or had been performed 2 years postoperatively in 40 eyes. A sample decision tree was produced with accuracy of 50% (likelihood ratio 0.8). The best artificial neural network, which showed 87% accuracy and a positive likelihood ratio of 8, was achieved with 40 neurons. The area under the receiver-operating-characteristic curve was 0.71. In comparison, logistic regression reached accuracy of 80%; however, the likelihood ratio was not measurable because the sensitivity was zero. CONCLUSION: A prototype artificial neural network was developed that predicted posterior capsule status (requiring capsulotomy) with reasonable accuracy. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Ultrasound biomicroscopy findings in fireworks-related blunt eye injuries.

PURPOSE: To present ultrasound biomicroscopic (UBM) findings and their clinical correlations in people with optically hazy media after injury at the Persian Wednesday Eve fireworks festival. METHODS: Ultrasound biomicroscopy was performed on a series of 32 eyes with severe closed-globe injuries by P40 ultrasound biomicroscope. RESULTS: The median age of the participants was 19 years, and 81.3% were male. All but one had gross hyphema. Seventy-five percent had an extension of the injury (at least) to Birmingham Eye Trauma Terminology zone II. Ultrasound biomicroscopy detected 3 more iridodialyses and 10 more cyclodialyses in addition to the respective 5 and 3 that were diagnosed clinically. Ten cases of angle recession were observed, and 5 were suggestive of subluxation of the crystalline lens. Two cases were suspected for anterior segment intraocular foreign body on clinical examination, but UBM and computed tomography scanning together ruled out such a diagnosis. CONCLUSIONS: Our study showed the value of UBM in the assessment of severely contused eyes and hyphema. It made possible evaluation for dialyses and recessions at presentation. Ultrasound biomicroscopy illustrated diverse subclinical disruptions in clinically invisible anterior segment structures.

Pain and Its Determinants in Photorefractive Keratectomy.

PURPOSE: To assess the determinants of early postoperative pain in photorefractive keratectomy. DESIGN: A prospective cross-sectional study. METHODS: One hundred and four myopic-astigmatic patients undergoing bilateral standard photorefractive keratectomy were evaluated for early postoperative pain severity. On day 1 postoperatively, the level of pain experienced was reported by the patient on a visual analog scale of 0 to 10. At the preoperative interview, data were collected on clinical, demographic, and social characteristics to find potential pain determinants. RESULTS: The median reported pain level was 3. About 20% of subjects reported a pain score of 6 or higher, and 2.9% (6 eyes of 4 patients) reported the highest pain score. The presence of external eye inflammatory signs was associated with higher levels of pain (P < 0.001). Patients with a higher body mass index reported more severe pain (P = 0.006). An inverse association was found between pain and harmful lifestyle choices (P = 0.008). Demographic characteristics, history of contact lens wear, history of major operation, past experience of severe pain, knowledge about the operation's adverse effects, preoperative insomnia, preoperative anxiety, operative factors, and refractive indices were not related to the severity of pain experienced (all P > 0.05). CONCLUSIONS: The association of pain with ocular surface inflammation suggests that inflammatory processes have a role in early postoperative pain, supporting the use of anti-inflammatory agents for pain management. Prescription of weight-adjusted dosages of analgesics is recommended on the basis of the association between severity of postoperative pain and body mass index.