RESUMO
PURPOSE: To determine the validity, accuracy and acceptability of the Image Warping Test (IWT), a novel test for the measurement of visual distortion in the central visual field. METHODS: 25 volunteers with metamorphopsia secondary to vitreoretinal pathology were recruited at a tertiary referral center. All subjects underwent ophthalmological examination and measurement of metamorphopsia via Amsler grid, Morphision, M-CHARTS and the IWT. Construct validity was determined through assessment of the association between symptoms, pathology, visual acuity, established metamorphopsia test results and IWT results. RESULTS: There was close association between subjective estimation of metamorphopsia severity and IWT score (p=0.005), between Morphision result and IWT score (p=0.015), and between the nature of vitreoretinal pathology and IWT score (p=0.007). There was no statistically significant correlation between best corrected distance visual acuity and IWT score, and between M-CHARTS score and IWT score. CONCLUSION: The IWT allows the creation of a digital map of subjective metamorphopsia which effectively measures its severity and nature, and opens the possibility to its non-invasive correction in future through inverse mapping of the distortion map onto live images.
RESUMO
Telemedicine, the use of telecommunication and information technology to deliver healthcare remotely, has evolved beyond recognition since its inception in the 1970s. Advances in telecommunication infrastructure, the advent of the Internet, exponential growth in computing power and associated computer-aided diagnosis, and medical imaging developments have created an environment where telemedicine is more accessible and capable than ever before, particularly in the field of ophthalmology. Ever-increasing global demand for ophthalmic services due to population growth and ageing together with insufficient supply of ophthalmologists requires new models of healthcare provision integrating telemedicine to meet present day challenges, with the recent COVID-19 pandemic providing the catalyst for the widespread adoption and acceptance of teleophthalmology. In this review we discuss the history, present and future application of telemedicine within the field of ophthalmology, and specifically retinal disease. We consider the strengths and limitations of teleophthalmology, its role in screening, community and hospital management of retinal disease, patient and clinician attitudes, and barriers to its adoption.
RESUMO
BACKGROUND: Retinopathy of prematurity (ROP), a leading cause of childhood blindness, is diagnosed through interval screening by paediatric ophthalmologists. However, improved survival of premature neonates coupled with a scarcity of available experts has raised concerns about the sustainability of this approach. We aimed to develop bespoke and code-free deep learning-based classifiers for plus disease, a hallmark of ROP, in an ethnically diverse population in London, UK, and externally validate them in ethnically, geographically, and socioeconomically diverse populations in four countries and three continents. Code-free deep learning is not reliant on the availability of expertly trained data scientists, thus being of particular potential benefit for low resource health-care settings. METHODS: This retrospective cohort study used retinal images from 1370 neonates admitted to a neonatal unit at Homerton University Hospital NHS Foundation Trust, London, UK, between 2008 and 2018. Images were acquired using a Retcam Version 2 device (Natus Medical, Pleasanton, CA, USA) on all babies who were either born at less than 32 weeks gestational age or had a birthweight of less than 1501 g. Each images was graded by two junior ophthalmologists with disagreements adjudicated by a senior paediatric ophthalmologist. Bespoke and code-free deep learning models (CFDL) were developed for the discrimination of healthy, pre-plus disease, and plus disease. Performance was assessed internally on 200 images with the majority vote of three senior paediatric ophthalmologists as the reference standard. External validation was on 338 retinal images from four separate datasets from the USA, Brazil, and Egypt with images derived from Retcam and the 3nethra neo device (Forus Health, Bengaluru, India). FINDINGS: Of the 7414 retinal images in the original dataset, 6141 images were used in the final development dataset. For the discrimination of healthy versus pre-plus or plus disease, the bespoke model had an area under the curve (AUC) of 0·986 (95% CI 0·973-0·996) and the CFDL model had an AUC of 0·989 (0·979-0·997) on the internal test set. Both models generalised well to external validation test sets acquired using the Retcam for discriminating healthy from pre-plus or plus disease (bespoke range was 0·975-1·000 and CFDL range was 0·969-0·995). The CFDL model was inferior to the bespoke model on discriminating pre-plus disease from healthy or plus disease in the USA dataset (CFDL 0·808 [95% CI 0·671-0·909, bespoke 0·942 [0·892-0·982]], p=0·0070). Performance also reduced when tested on the 3nethra neo imaging device (CFDL 0·865 [0·742-0·965] and bespoke 0·891 [0·783-0·977]). INTERPRETATION: Both bespoke and CFDL models conferred similar performance to senior paediatric ophthalmologists for discriminating healthy retinal images from ones with features of pre-plus or plus disease; however, CFDL models might generalise less well when considering minority classes. Care should be taken when testing on data acquired using alternative imaging devices from that used for the development dataset. Our study justifies further validation of plus disease classifiers in ROP screening and supports a potential role for code-free approaches to help prevent blindness in vulnerable neonates. FUNDING: National Institute for Health Research Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and the University College London Institute of Ophthalmology. TRANSLATIONS: For the Portuguese and Arabic translations of the abstract see Supplementary Materials section.
Assuntos
Aprendizado Profundo , Retinopatia da Prematuridade , Recém-Nascido , Lactente , Humanos , Criança , Estudos Retrospectivos , Retinopatia da Prematuridade/diagnóstico , Sensibilidade e Especificidade , Recém-Nascido PrematuroRESUMO
We report cases of acute angle closure in 2 young highly myopic siblings with Knobloch syndrome. To our knowledge, this is the first report of acute angle closure in Knobloch syndrome. Both patients were homozygous for a likely pathogenic variant in COL18A1. Both responded to treatment with cyclophotocoagulation and remained stable despite declining or being medically unfit for clear lens extraction. We argue that the recent implication of heterozygous mutations in COL18A1 in familial angle closure supports the argument that acute angle closure in these 2 patients was likely to be a thus far unreported feature of Knobloch syndrome. In addition, these cases also support the hypothesis that pathogenic variants in COL18A1 may be a risk factor for acute angle closure.
Assuntos
Glaucoma de Ângulo Fechado , Degeneração Retiniana , Descolamento Retiniano , Encefalocele , Glaucoma de Ângulo Fechado/cirurgia , Humanos , Pressão Intraocular , Descolamento Retiniano/congênitoAssuntos
Betacoronavirus , Infecções por Coronavirus , Tratamento de Emergência , Oftalmologia , Pandemias , Pneumonia Viral , Atitude do Pessoal de Saúde , COVID-19 , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , SARS-CoV-2 , Reino UnidoRESUMO
PURPOSE: Autologous hemoderivative eye drops have a role in the management of persistent epithelial defects (PEDs), but their use may be limited by cost and availability. Finger-prick autologous blood (FAB) treatment uses whole capillary blood, obtained from a sterilized fingertip, as an alternative form of hemoderivative eye drop therapy. To date, 1 report has described the safe and effective use of FAB for dry eye and PEDs. We report the results of 10 eyes (10 patients) treated with FAB for PEDs. METHODS: Ten patients with PEDs in 1 eye for a mean of 259 ± 201 days due to diabetic neurotrophic keratopathy (n = 3), herpetic keratitis (n = 3), postpenetrating keratoplasty (n = 1), keratoconjunctivitis sicca (n = 1), postradiotherapy (n = 1), and neuropathic ulcer (n = 1) were treated with FAB 4 times a day for 28 days in addition to conventional therapies. All patients had been unsuccessfully treated with conventional therapy before commencing on FAB. None of the patients had received any surgical treatment for PED. RESULTS: At day 28, the PED had healed in 60% (n = 6) of the eyes. In 1 eye, the PED reduced in size by half. Thirty percent (n = 3) of patients had incomplete follow-up data at the end of the study. CONCLUSIONS: FAB in combination with conventional treatment may be successfully used in the management of refractory PEDs. No adverse effects arising from FAB treatment were observed.
Assuntos
Doenças da Córnea/terapia , Epitélio Corneano/patologia , Idoso , Idoso de 80 Anos ou mais , Sangue , Doenças da Córnea/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Microscopia com Lâmpada de Fenda , Resultado do TratamentoRESUMO
BACKGROUND: Ophthalmic emergencies comprise a significant portion of junior doctors' workload in accident and emergency (A&E). However, previous studies have demonstrated a lack of training and confidence in the management of such emergencies. This study assessed changes in basic ophthalmic training that A&E junior doctors received in dealing with eye emergencies, their perceived level of confidence and the availability of appropriate ophthalmic equipment in A&E over the last 15 years. METHODS: A prospective, national, combined online and telephone survey using a previously published questionnaire was performed. Foundation year two doctors (FY2s) from each A&E department in the UK listed on the official NHS directory were contacted for participation. RESULTS: Two hundred and ten A&E departments were contacted and 202 responded (response rate of 96.2%). There was no significant change in the number of A&E departments equipped with slit lamps (82.5% in 2003 vs 79.7% in 2018; p = 0.26). However, the prevalence of training in its use has decreased significantly (68.4% in 2003 vs 52% in 2018; p = 0.005). There was also a significant reduction in the prevalence of training in the management of eye emergencies (77.4% in 2003 vs 45.5% in 2018; p < 0.001) and the proportion of FY2s who felt confident in dealing with such cases (36.1% in 2003 vs 6% in 2018; p < 0.001). CONCLUSION: There is a concerning decline in basic ophthalmic training for A&E FY2s, reflected by the alarmingly low level of confidence in the management of eye emergencies. This highlights an urgent need to improve ophthalmic training for junior doctors in A&E.
Assuntos
Emergências , Serviço Hospitalar de Emergência , Humanos , Corpo Clínico Hospitalar , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
A 73-year-old woman with bilateral previous radial keratotomies (RK) and symptomatic cataracts was referred. The uncorrected distance visual acuity (UDVA) was 0.24 logarithm of the minimum angle of resolution (logMAR) in the left eye and 0.32 logMAR in the left eye. The American Society of Cataract and Refractive Surgery calculator for eyes with previous RK was used for intraocular lens (IOL) power calculation. The dominant left eye had uneventful cataract extraction with monofocal IOL implantation. For the nondominant right eye, a small-aperture posterior chamber IOL with the highest available power was used; this was followed by planned secondary piggyback sulcus IOL implantation for the expected residual refractive error. The UDVA after the primary procedure was 0.50 logMAR in the right eye and 0.10 logMAR in the left eye. After the planned secondary procedure, the UDVA was -0.10 logMAR in both eyes with a -0.50 diopter spherical equivalent and the patient did not require spectacles for near, intermediate, or distance vision.
Assuntos
Extração de Catarata , Ceratotomia Radial , Implante de Lente Intraocular/métodos , Lentes Intraoculares , Idoso , Feminino , Humanos , Resultado do Tratamento , Acuidade VisualRESUMO
BACKGROUND: Bleb needling is widely used to restore flow and lower intraocular pressure (IOP) in a failing trabeculectomy. We aimed to measure the safety and efficacy of needling in a large cohort and identify factors that were associated with success and failure. METHODS: This retrospective audit included all patients who underwent needling at Addenbrooke's Hospital, Cambridge over a 10-year period. Data were available on 91 patients (98% of patients identified), including 191 needlings on 96 eyes. Success was defined as IOP below 21 mm Hg or 16 mm Hg or 13 mm Hg consistently, without reoperation or glaucoma medication. Risk factors for failure were assessed by Cox proportional hazard regression and Kaplan-Meier curves. RESULTS: Success defined as IOP <16 mm Hg was 66.6% at 12 months and 53% at 3 years and success defined as IOP <21 mm Hg was 77.1% at 12 months and 73.1% at 3 years. Failure after needling was most common in the first 6 months. Factors that predicted failure were flat or fibrotic blebs (non-functional) and no longer injected, while success was predicted by achieving a low IOP immediately after needling. No significant complications were identified. CONCLUSION: Needling was most successful soon after trabeculectomy, but resuscitation of a long-failed trabeculectomy had lower likelihood of success. The safety and efficacy compare favourably with alternative treatment approaches.
Assuntos
Glaucoma/cirurgia , Pressão Intraocular/fisiologia , Agulhas , Estomas Cirúrgicos , Trabeculectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Glaucoma/fisiopatologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Tonometria Ocular , Acuidade Visual/fisiologiaRESUMO
PURPOSE: Evaluation of outcomes in retinal vein occlusions (RVOs) for: (1) multiple repeat dexamethasone (DEX) injections and (2) conversion from DEX to ranibizumab. METHODS: We conducted a retrospective study evaluating outcomes of multiple DEX injections and those requiring conversion to ranibizumab at Moorfields Eye Hospital, Bedford, UK. All patients had undergone a complete ophthalmic work-up. RESULTS: Patients (n = 129) had a mean follow-up of 19.9 months. The mean improvement in central retinal thickness was 312 µm after final DEX (p = <0.0001). Mean peak best corrected visual acuity (BCVA) after final DEX was an improvement of 16 ETDRS letters (p < 0.0001). Forty-nine patients were converted and received a mean of 9.37 ranibizumab injections with a mean improvement in BCVA of 15 ETDRS letters (p < 0.0001) compared with final DEX. CONCLUSIONS: This study supports the use of ranibizumab in eyes previously treated with DEX and provides long-term efficacy and safety data for multiple DEX injection.
Assuntos
Dexametasona/administração & dosagem , Substituição de Medicamentos/métodos , Macula Lutea/patologia , Edema Macular/tratamento farmacológico , Ranibizumab/administração & dosagem , Oclusão da Veia Retiniana/tratamento farmacológico , Acuidade Visual/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Inibidores da Angiogênese/administração & dosagem , Implantes de Medicamento , Feminino , Angiofluoresceinografia , Seguimentos , Fundo de Olho , Glucocorticoides/administração & dosagem , Humanos , Injeções Intravítreas , Edema Macular/diagnóstico , Edema Macular/etiologia , Masculino , Pessoa de Meia-Idade , Oclusão da Veia Retiniana/complicações , Oclusão da Veia Retiniana/diagnóstico , Estudos Retrospectivos , Fatores de Tempo , Tomografia de Coerência Óptica , Resultado do TratamentoRESUMO
The sensations of pain, itch, and cold often interact with each other. Pain inhibits itch, whereas cold inhibits both pain and itch. TRPV1 and TRPA1 channels transduce pain and itch, whereas TRPM8 transduces cold. The pruritogen chloroquine (CQ) was reported to excite TRPA1, leading to the sensation of itch. It is unclear how CQ excites and modulates TRPA1(+), TRPV1(+), and TRPM8(+) neurons and thus affects the sensations of pain, itch, and cold. Here, we show that only 43% of CQ-excited dorsal root ganglion neurons expressed TRPA1; as expected, the responses of these neurons were completely prevented by the TRPA1 antagonist HC-030031. The remaining 57% of CQ-excited neurons did not express TRPA1, and excitation was not prevented by either a TRPA1 or TRPV1 antagonist but was prevented by the general transient receptor potential canonical (TRPC) channel blocker BTP2 and the selective TRPC3 inhibitor Pyr3. Furthermore, CQ caused potent sensitization of TRPV1 in 51.9% of TRPV1(+) neurons and concomitant inhibition of TRPM8 in 48.8% of TRPM8(+) dorsal root ganglion neurons. Sensitization of TRPV1 is caused mainly by activation of the phospholipase C-PKC pathway following activation of the CQ receptor MrgprA3. By contrast, inhibition of TRPM8 is caused by a direct action of activated Gαq independent of the phospholipase C pathway. Our data suggest the involvement of the TRPC3 channel acting together with TRPA1 to mediate CQ-induced itch. CQ not only elicits itch by directly exciting itch-encoding neurons but also exerts previously unappreciated widespread actions on pain-, itch-, and cold-sensing neurons, leading to enhanced pain and itch.