Digital eye strain in young screen users: A systematic review.

Digital eye strain (DES) or computer vision syndrome (CVS) is a phenomenon linked to ever increasing digital screen use globally, affecting a large number of individuals. Recognizing causative and alleviating factors of DES may help establish appropriate policies. We aimed to review factors that aggravate or alleviate DES symptoms in young, i.e. pre-presbyopic (< 40 years old), digital device users. We searched PubMed, Scopus, EMBASE, Cochrane, Trip Database, and grey literature up to 1st July 2021. Among a plethora of studies with heterogeneous diagnostic criteria for DES, we only included those using a validated questionnaire for the diagnosis and evaluating associated factors in young subjects. Relevant data were extracted, risk of bias assessment of the included studies and GRADE evaluation of each outcome were performed. Ten studies were included (five interventional, five observational) involving 2365 participants. Evidence coming from studies with moderate risk of bias suggested that blue-blocking filters do not appear to prevent DES (2 studies, 130 participants), while use of screens for > 4-5 h/day (2 studies, 461 participants) and poor ergonomic parameters during screen use (1 study, 200 participants) are associated with higher DES symptoms' score. GRADE evaluation for the outcomes of blue-blocking filters and duration of screen use showed low to moderate quality of evidence. It appears advisable to optimize ergonomic parameters and restrict screen use duration, for minimizing DES symptoms. Health professionals and policy makers may consider recommending such practices for digital screen users at work or leisure. There is no evidence for use of blue-blocking filters.

Reliability of Refraction, Keratometry, and Intraocular Pressure Measurements with an Automated All-in-one Device.

SIGNIFICANCE: This study explores the reliability of TonoRef II (Nidek, Tokyo, Japan), which represents a simple tool to obtain rapid refractometry and tonometry measurements. The present device demonstrates very high repeatability of refraction and intraocular pressure (IOP) readings as compared with subjective measurements and a higher concordance of IOP readings to Goldmann application tonometry (GAT). PURPOSE: This study aimed to evaluate the repeatability of measurements acquired with the Autorefractometer/Keratometer/Tonometer TonoRef II and assess their agreement to subjective measurements and readings of other established devices. METHODS: In a cross-sectional study, 54 eyes of 54 healthy subjects were enrolled. Each subject underwent five measurements with the TonoRef II, three measurements with the Canon RK-F1 Autorefractor Keratometer (Canon Europe NV, Amstelveen, the Netherlands), three IOP measurements with the Canon TX-F Noncontact Tonometer (Canon Inc., Tokyo, Japan), three measurements with GAT, and a thorough subjective refraction. Repeatability coefficient (r), intraclass correlation coefficient (ICC), and Bland-Altman plots were used to evaluate repeatability of readings and agreement to the subjective values. RESULTS: TonoRef II showed high repeatability (ICC >0.9) in all parameters tested (sphere, r = 0.157; cylinder, r = 0.196; IOP, r = 2.653). A strong correlation was found between TonoRef and Canon instruments (P < .001 in all parameters). Mean differences and limits of agreement (mean ± 1.96 standard deviation) were -0.01 ± 0.69 D, -0.11 ± 0.7 D, and 2.1 ± 3.4 mmHg for sphere, cylinder, and IOP, respectively. Both autorefractors achieved a very good to excellent agreement to the values obtained with the subjective refraction for most of the parameters tested, without any significant difference to each other (P > .05). Intraocular pressure measurements of TonoRef II showed higher agreement to the GAT values compared with those obtained with the Canon tonometer (ICC, 0.9114 and 0.7002, respectively; P < .001). CONCLUSIONS: Intraocular pressure and refraction readings acquired with TonoRef II demonstrate very high repeatability and agreement to the subjective measurements. Regarding IOP evaluation, TonoRef II shows higher concordance to GAT compared with another established noncontact tonometer.

Iridocorneal angle assessment in children with spontaneously regressed retinopathy of prematurity.

PURPOSE: To assess anterior segment anatomic parameters in school-aged children with spontaneously regressed retinopathy of prematurity (sr-ROP) and in children born preterm without ROP history (preT). METHODS: sr-ROP and preT children were compared with healthy, born at term children (control group). Biometric characteristics were measured with the IOLMaster. Iridocorneal angle structure was evaluated using Visante AS-OCT, and angle opening distance, trabecular iris space area and scleral spur angle were calculated. Best-corrected visual acuity (BCVA) was measured with the ETDRS chart. RESULTS: We examined 22 eyes of 11 children with sr-ROP, 26 eyes of 13 preT children and 24 eyes of 12 healthy controls, with a median age of 8 years. sr-ROP children exhibited worse mean BCVA and reduced AL compared to controls (p = 0.001 and p = 0.007, respectively). A narrower iridocorneal angle was found in sr-ROP compared to the preT and the control groups. Preterm children were found to have similar anterior chamber angle metrics compared to the full-term control group. CONCLUSION: In this study, school-aged children with a history of sr-ROP had narrower angles compared to preterm- and term-born children. AS-OCT demonstrated structural differences of the iridocorneal angle in sr-ROP, possibly reflecting a mild developmental arrest of the anterior segment.

Alternative mydriasis techniques for retinopathy of prematurity screening.

PURPOSE: There is a large variation in mydriatic regimens used in screening for retinopathy in preterm infants. Except for the standard instillation of mydriatic drops in their commercial formulation, other techniques for pupil dilation have also been described. This study aimed to review all techniques that have been used for mydriasis in retinopathy of prematurity eye examination (ROPEE) screening. METHODS: A comprehensive literature search was performed in PubMed, Cochrane library, Trip database, and Scopus, using the key words: "mydriasis", "techniques", "mydriatics", "dilating drops", "retinopathy of prematurity", "ROP", "phenylephrine", "cyclopentolate", "tropicamide", "smaller mydriatic drops", "reduction in drop size" to February 2019. RESULTS: Five primary studies were included, assessing the techniques of microdrops, lower conjunctival fornix (LCF) packing and Mydriasert® ophthalmic insert. Reported efficacy was similar to commercial eyedrops instillation. Microdrops appeared to have a superior safety profile. LCF packing and Mydriasert lead to increased blood pressure, without serious complications, necessitating further safety studies. CONCLUSIONS: Of all alternative mydriasis techniques for ROPEE screening that have been described, microdrops appear to be the safest yet still effective technique in the fragile population of premature infants in risk of ROP.

Efficacy and safety of interventions to control myopia progression in children: an overview of systematic reviews and meta-analyses.

BACKGROUND: Myopia is a common visual disorder with increasing prevalence. Halting progression of myopia is critical, as high myopia can be complicated by a number of vision-compromising conditions. METHODS: Literature search was conducted in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE) and Centre for Reviews and Dissemination (CRD) Health Technology Assessment (HTA) database. Systematic reviews and meta-analyses investigating the efficacy and safety of multiple myopia interventions vs control conditions, were considered. Methodological quality and quality of evidence of eligible studies were assessed using the ROBIS tool and GRADE rating. The degree of overlapping of index publications in the eligible reviews was calculated with the corrected covered area (CCA). RESULTS: Forty-four unique primary studies contained in 18 eligible reviews and involving 6400 children were included in the analysis. CCA was estimated as 6.2% and thus considered moderate. Results demonstrated the superior efficacy of atropine eyedrops; 1% atropine vs placebo (change in refraction: -0.78D, [- 1.30 to - 0.25] in 1 year), 0.025 to 0.05% atropine vs control (change in refraction: -0.51D, [- 0.60 to - 0.41] in 1 year), 0.01% atropine vs control (change in refraction: -0.50D, [- 0.76 to - 0.24] in 1 year). Atropine was followed by orthokeratology (axial elongation: - 0.19 mm, [- 0.21 to - 0.16] in 1 year) and novel multifocal soft contact lenses (change in refraction: -0.15D, [- 0.27 to - 0.03] in 1 year). As regards adverse events, 1% atropine induced blurred near vision (odds ratio [OR] 9.47, [1.17 to 76.78]) and hypersensitivity reactions (OR 8.91, [1.04 to 76.03]). CONCLUSIONS: Existing evidence has failed to convince doctors to uniformly embrace treatments for myopic progression control, possibly due to existence of some heterogeneity, reporting of side effects and lack of long-term follow-up. Research geared towards efficient interventions is still necessary.

'The role of accommodative function in myopic development: A review.'

Involvement of the accommodative mechanism in myopia progression has been hypothesised and investigated over the past years. The initial stimulus for accommodation is derived from near work, in an attempt of the eye to obtain a clear image. When there is a lag in accommodative response, the resulting blurred retinal image is believed to precipitate axial elongation and lead to myopia development. Given the myopia crisis across the globe, the phenomenal connection between the accommodative mechanism and myopia development warrants further investigation. The dynamic accommodative functions implicated in binocular vision evaluation include the accommodative accuracy, amplitude and facility. Association of these accommodative parameters to current treatment options for myopia control is of great clinical interest. Effective treatments, including orthokeratology, multifocal lenses and atropine eyedrops, appear to induce changes in the dynamic accommodative response. This review aims at investigating the clinical role of accommodative function in myopia development and at exploring its use as a promising myopia-monitoring tool.

Part-time Versus Full-time Spectacles for Myopia Control (ParMA Study): A Randomized Clinical Trial.

Introduction To compare myopia progression in school-aged children of Caucasian origin wearing part-time vs. full-time full correction with single-vision spectacles. Methods This prospective, randomized controlled trial included 30 children with bilateral myopia, who received either full-time or part-time treatment with single-vision spectacle lenses. Myopia progression was assessed as the mean change in cycloplegic spherical equivalent refraction (SE), mean change in axial length (AL), and mean change in sub-foveal choroidal thickness (SChT), over a 12-month follow-up period. Results A total of 32 eyes were treated with part-time single-vision spectacles (intervention group) and 28 eyes with full-time single-vision spectacles (control group), respectively. The part-time treated group reported no spectacle use during near-work activities for a mean of 6.2 hours/day. At the 12-month assessment, there was no significant difference between part-time and full-time correction groups in mean SE change (MD: -0.05 D, 95% CI: -0.50 - 0.39 D; P 0.81), in mean AL change (MD: -0.07 mm; 95% CI: -0.20 - 0.06 mm; P 0.30), and in mean SChT change (MD: -11.45 µm; 95% CI -22.60 - 14.16 µm; P 0.67). Conclusion Myopia progression in Caucasian children treated with part-time, single-vision spectacle use was not different compared to full-time, single-vision spectacle use, over a 12-month follow-up period.

Factors predisposing to intraoperative floppy-iris syndrome: An up-to-date meta-analysis.

Intraoperative floppy-iris syndrome (IFIS) is an increasingly recognized condition that is proven to lead to higher rates of intraoperative complications. This study provides an updated systematic review and meta-analysis regarding all the identified factors predisposing to IFIS. The study was performed in accordance with the PRISMA guidelines. 38 studies were finally included in the meta-analysis. The factors that were found to predispose to IFIS significantly were male sex (odds ratio [OR], 4.25; CI, 2.58-7.01), hypertension (OR, 1.55; CI, 1.01-2.37), tamsulosin (OR, 31.06; CI, 13.74-70.22), finasteride (OR, 4.60; CI, 1.97-10.73), benzodiazepines (OR, 2.88; CI, 1.17-7.12), and antipsychotics intake (OR, 6.91; CI, 2.22-21.50). A decreased dilated pupil preoperatively was found predisposing to IFIS (weighted mean difference -0.93; CI, -1.19 to -0.67). Intracameral epinephrine, which was investigated as a potential prophylactic measure for preventing IFIS, did not reach statistical significance (OR, 0.29; CI, 0.08-1.06). A comprehensive preoperative assessment of all risk factors is vital to stratify the surgical risk, which is crucial in addressing IFIS because unanticipated IFIS could turn a routine surgery into one of significant visual morbidity.

Choroidal thickness and ocular growth in childhood.

The involvement of the choroid in ocular growth regulation has been postulated in studies showing that refractive errors correlate with alterations in choroidal thickness (ChT). The advent of optical coherence tomography imaging has enabled qualitative and quantitative assessment of the choroid. In children, ChT changes correlate with a number of ocular pathologies, including myopia, retinopathy of prematurity, and amblyopia. We synthesize mechanisms and evidence regarding choroidal thickness variation during childhood. Subfoveal ChT is influenced by a number of factors including age, ethnicity, gender, axial length, and intraocular pressure. Myopic eyes have thinner choroids compared to emmetropic and hyperopic eyes. ChT may in fact serve as a marker of myopic progression, as ChT thinning occurs early during myopic development, but this association has not been established quantitatively. In addition, subfoveal ChT appears thicker in amblyopic eyes, while prematurity and retinopathy of prematurity may be associated with thinner ChT. Overall, both animal models and clinical research indicate that ChT induces or reflects physiological changes in the eye pertaining to ocular growth or maturation.

Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?

Assisted dying is a highly controversial moral issue incorporating both physician-assisted dying (PAD) and voluntary active euthanasia. End-of-life practices are debated in many countries, with assisted dying receiving different consideration across various jurisdictions. In this paper, we provide an analytic framework of the current position and the main arguments related to the rights and moral principles concerning assisted dying. Assisted dying proponents focus on the respect of autonomy, self-determination and forestalling suffering. On the other hand, concerns are raised regarding the interpretation of the constitutional right to life and balancing this with the premise of assisted dying, alongside the impacts of assisted dying on the doctor-patient relationship, which is fundamentally based on trust, mutual respect and the premise of 'first do no harm'. Our review is underpinning the interpretation of constitutional rights and the Hippocratic Oath with the premise of assisted dying, alongside the impacts of assisted dying on the doctor-patient relationship. Most clinicians remain untrained in such decision making, with fears against crossing key ethical divides. Due to the increasing number of cases of assisted dying and lack of consensus, our review enables the integration of ethical and legal aspects and facilitates decision making.

Safety and efficacy of denosumab in osteoporotic patients previously treated with other medications: a systematic review and meta-analysis.

INTRODUCTION: Denosumab is a monoclonal antibody that received approval by the FDA for the treatment of osteoporosis in 2010. Available higher level research evidence concerns the treatment of patients that have not received any anti-osteoporotic medication in the past. Further investigation is warranted, since clinicians often face the challenge of administering the most efficacious drug in patients, pretreated with other medications. AREAS COVERED: We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of denosumab compared to other active anti-osteoporotic agents in patients formerly receiving other treatments. We searched MEDLINE, EMBASE, CENTRAL, the metaRegister of Controlled Trials (mRCT) and clinicaltrials.gov up to April 2017 to identify eligible trials in patients with primary osteoporosis. EXPERT OPINION: Our meta-analysis included 6 Randomised Controlled Trials encompassing 2968 patients formerly treated with anti-osteoporotic medications. Quantitative data synthesis demonstrated superiority of denosumab in augmenting Bone Mineral Density in all skeletal sites studied compared to controls [treatment difference in total hip: 1.59% (95% CI 1.01, 2.17)], whereas the overall incidence of serious adverse events was not increased (OR 1.12, 95% CI 0.85 to 1.47, p = 0.42). Future research geared towards the fracture incidence, quality of life and patient reported outcomes is warranted.

Clinical and laboratory characteristics, epidemiology, and outcomes of murine typhus: A systematic review.

Murine or endemic typhus, a febrile disease caused by Rickettsia typhi, is often misdiagnosed due to its non-specific presentation. We sought to evaluate all available evidence in the literature regarding the clinical and laboratory manifestations, epidemiological characteristics, and outcomes of murine typhus. Pubmed was searched for all articles providing available data. In an effort to incorporate contemporary data, only studies from 1980 were included. Thirty-three case series including 2074 patients were included in final analysis. Available evidence suggests that the classic triad of fever, headache and rash is encountered in only one-third of patients. Other frequent symptoms were chills, malaise, myalgia, and anorexia. A tetrad of reported laboratory abnormalities consisting of elevated liver enzymes, lactate dehydrogenase, erythrocyte sedimentation rate and hypoalbuminemia was detected. Complications were observed in one-fourth of patients, reported mortality was extremely low, but untreated patients had notably longer duration of fever. Among epidemiological characteristics, a seasonal distribution with most cases reported during warmer months, was the most prominent finding. Murine typhus in children exhibits several different characteristics, with abdominal pain, diarrhea, and sore throat reported more commonly, higher frequency of anemia, lower frequency of hypoalbuminemia, hematuria and proteinuria and a much lower rate of complications. This systematic review of published evidence provides a thorough description of the clinical and laboratory features of murine typhus and highlights important differences in children.

Safety and efficacy of chloral hydrate for procedural sedation in paediatric ophthalmology: a systematic review and meta-analysis.

PURPOSE: Although chloral hydrate (CH) has been used as a sedative for decades, it is not widely accepted as a valid choice for ophthalmic examinations in uncooperative children. This study aimed to systematically review the literature on the drug's safety and efficacy. METHODS: We searched PubMed, EMBASE, ISI Web of Science, Scopus, CENTRAL, Google Scholar and Trip database to 1 October 2015, using the keywords 'chloral hydrate', 'paediatric' and 'procedural sedation OR diagnostic sedation'. A meta-analysis of randomised controlled trials (RCTs) was performed. RESULTS: A total of 6961 articles were screened and 104 were included in the review. Thirteen of these concerned paediatric ophthalmic examination, while 13 others were RCTs and were meta-analysed. CH was reported to have been administered in a total of 24 265 sedation episodes in children aged from <1 month to 18 years. The meta-analysis showed CH had a higher OR (2.95, 95% CI 1.09 to 7.99) for successful sedation compared to other sedatives, but significant limitations apply. The commonest reported adverse events (AE) were not serious (eg, paradoxical reaction or transient vomiting) and required no intervention. Severe AE, including two deaths, were related to comorbidity, overdose or aspiration. CONCLUSIONS: Despite the paucity of high quality evidence, the existing literature suggests that the use of CH for procedural sedation in children appears to be an effective alternative to general anaesthesia, and it can be safe when administered in the hospital setting with appropriate monitoring and vigilance for intervention.

Interventions to control myopia progression in children: protocol for an overview of systematic reviews and meta-analyses.

BACKGROUND: Myopia is a common visual disorder with increasing prevalence among developed countries of the world. Myopia constitutes a substantial risk factor for several ocular conditions that can lead to blindness. The purpose of this study is to conduct an overview of systematic reviews and meta-analyses in order to identify and appraise robust research evidence regarding the management of myopia progression in children and adolescents. METHODS: A literature search will be conducted in MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), and Health Technology Assessment (HTA) Database via Centre for Reviews and Dissemination (CRD). We will search for systematic reviews or meta-analyses that examine optical or pharmaceutical modalities for myopia control. Two independent overview authors will screen the titles and abstracts against the eligibility criteria. Individual study's methodological quality and quality of evidence for each outcome of interest will be assessed by two independent authors using the ROBIS tool and GRADE rating, respectively. In cases of disagreement, consensus will be reached with the help of a third author. Our primary outcomes will be the mean change in refractive error, mean axial length change, and adverse events. A citation matrix will be generated, and the corrected covered area (CCA) will be estimated, in order to identify overlapping primary studies. Possible meta-biases and measures of heterogeneity will be described, and cases of dual co-authorship will be identified and discussed. If any recently published randomized controlled trials (RCTs) are detected, these will be appraised and their findings will be presented. An overall summary of outcomes will be provided using descriptive statistics and will be supplemented by narrative synthesis. DISCUSSION: This overview will examine the high level of existing evidence for treatment of myopia progression. Efficient interventions will be identified, and side effects will be reported. The expected benefit is that all robust recent research evidence will be compiled in a single study. The results may inform future research in this area, which should provide insight into the appropriate regimes for the administration of these modalities and contribute to future guideline development. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017068204.