Pediatric Eye Care Treatment Rates and Community Compliance to a Spectacle Provision Program in an Underserved School District in San Diego, CA.

Significance: The need for early identification and treatment of young children's refractive error needs has become a public health concern. The UCSD Eyemobile for Children (EyeMobile) provides vision screenings and comprehensive eye exams on the Eyemobile among a population of underserved, predominantly Hispanic preschool and elementary school children. The program also provides spectacles for children who fail eye exams due to refractive error. Methods: We performed a retrospective cross-sectional analysis of all children screened from 2011 to 2017 by the Eyemobile across 10 San Diego elementary schools. We examined demographics, distance and near visual acuity, autorefraction, stereopsis, and color vision. To measure compliance to our spectacle program, we checked if children who were prescribed spectacles were wearing them, as instructed, at the following year's screening. Differences between compliance measures with respect to school, age, ethnicity, and gender were determined using chi-square analysis, while all other measures were fit to a binary logistic regression to determine statistically significant factors. Results: A total of 12,176 elementary school children were screened between 2011 and 2017. Of these children, 5269 (43.3%) were referred for a comprehensive eye examination. Across six years, 3163 (60.0%) of the children referred completed their eye examinations. There was a significant increase (p < 0.001) in exam completion in the successive years. Exam completion was significantly higher in ten-year-olds (p = 0.0278) and in 3 of the 10 schools (p < 0.0001, p = 0.0027, and p = 0.0309). A total of 1089 (8.9% of screened) children were prescribed spectacles. Of the 409 children that were recorded with the compliance method, 342 (83.6%) were found to be fully compliant and wearing their spectacles as prescribed. Conclusion: The Eyemobile program demonstrated high levels of compliance for both eye examination completion and prescribed spectacle wear in underserved populations in the San Diego region, compared to similar national programs.

The PlusoptiX Photoscreener and the Retinomax Autorefractor as Community-based Screening Devices for Preschool Children.

PURPOSE: To compare the performance of the PlusoptiX S12 mobile photoscreener and the Retinomax K+3 Autorefractor as screening devices in preschool children. METHODS: Children ranging from 3 to 5 years of age from 11 San Diego County preschools underwent vision screening in their schools where ambient light could not always be controlled using both the Retinomax and the PlusoptiX. Cycloplegic refraction on the consented children was subsequently performed on the UCSD EyeMobile for children on-site at the school locations. RESULTS: A total of 321 children were screened with the PlusoptiX and Retinomax. The PlusoptiX referred 22% of children, of whom 70% of the referrals were read as "unable". The Retinomax referred 13% and there were no "unables". Similar results occurred in the cycloplegic-refracted 182 consented children-64% of the PlusoptiX referrals were read as "unable" . Only one third of these "unables" required glasses. Both devices referred the four children with amblyopia and one case of strabismus. However, PlusoptiX's 3 false negatives had amblyopia risk factors (ARFs) while the one Retinomax's false negative did not have ARFs. The Retinomax screening had 95% sensitivity and 94% specificity. The PlusoptiX screening had 86% sensitivity and 84% specificity. CONCLUSION: In this preschool population and environment, the PlusoptiX referred 63% more than the Retinomax in addition to a lower specificity and sensitivity. Adjusting PlusoptiX referral criteria might not substantially improve the specificity of the PlusoptiX due to the high numbers of "unables".

Refractive Errors and Amblyopia in the UCLA Preschool Vision Program; First Year Results.

PURPOSE: To report the outcomes of full ophthalmic examination for preschool children in LA County who failed screening with the Retinomax Autorefractor. DESIGN: Retrospective, cross-sectional study. METHODS: Between August 2012 and May 2013, the University of California Los Angeles (UCLA) preschool vision program screened 11 260 preschool children aged 3-5 years in Los Angeles County using the Retinomax Autorefractor only. Of those, 1007 children who failed the screening were examined by an ophthalmologist on the UCLA Mobile Eye Clinic. Data from the eye examination were recorded for all children. Amblyopia was defined as unilateral if there was ≥2 line interocular difference in the best-corrected visual acuity (BCVA) and as bilateral if BCVA was <20/50 for children <4 years old and <20/40 for children ≥4 years old. RESULTS: Glasses were prescribed for 740 (74%) of those examined. Uncorrected visual acuity for all examined children was 0.4 ± 0.2 (logMAR mean ± SD), and BCVA was 0.2 ± 0.1. Of the 88% who underwent cycloplegia, 58% had hyperopia (spherical equivalent [SE] ≥+0.50 diopter [D]), mean of +2.50 D, and 21% had myopia (SE ≤-0.50 D), mean of -1.40 D. A total of 69% had astigmatism ≥1.50 D, mean of 1.97 D (range 0-5.75). Spherical and cylindrical anisometropia ≥1.00 D were each found in 26% of those examined. Refractive amblyopia was found in 9% of those examined, or 0.8% of the original population. Of the amblyopic subjects, 77% were unilateral. CONCLUSIONS: Screening of preschoolers with the Retinomax led to diagnosis and early treatment of uncorrected refractive errors and amblyopia. By treating children early, amblyopia may be prevented, quality of life improved, and academic achievements enhanced.

The UCLA preschool vision program, 2012-2013.

PURPOSE: To introduce the University of California Los Angeles (UCLA) Preschool Vision Program (UPVP) and describe the utilization pattern and challenges of the first year of implementation. METHODS: The UPVP aims to improve vision in 3- to 5-year-old preschoolers of Los Angeles County. On the first visit, trained personnel use a handheld autorefractometer (Retinomax 3; Righton, Japan) for initial screening and identify those who would benefit from a complete eye examination. On the second visit, the UCLA Mobile Eye Clinic staff and ophthalmologists provide follow-up examinations. Prescribed eyeglasses are fit and provided by program personnel on the school site on a separate visit. Follow-up calls are made to ensure compliance. RESULTS: From a population of 12,088 children in 215 preschools, 11,260 preschoolers (mean age, 4.3 years; 49.2% females) were screened successfully. In this sample, 86% were Latino, and almost all (97%) spoke either Spanish or English. About 65% of referred preschoolers underwent a complete eye examination. Prescription eye glasses were provided for 850 preschoolers (7.5%); 95 children (0.8%) were newly diagnosed with amblyopia. CONCLUSIONS: A large proportion of Los Angeles County preschoolers with refractive errors have unmet needs in terms of refractive correction. Further studies are recommended to understand barriers to eye care for children and to devise initiatives for Los Angeles's large, densely populated, and complex community to increase awareness and willingness.

Impact of fenestrations and surface profiling on the holding of tissue by parallel occlusion laparoscopic graspers.

BACKGROUND: Despite the importance of efficient grasping during laparoscopic surgery, the published literature on jaw features, e.g., fenestrations and surface profiling on grasping efficiency defined as resistance to slip without inflicting trauma, is limited. METHODS: Various surface geometries of the jaws were tested with respect to (i) inclusion of fenestrations; (ii) surface contact to fenestration area ratio, and (iii) surface profiling of the jaws. Various loads were applied to the tissue which was subsequently pulled at a constant rate until free from the jaws. The maximal force necessary to pull the tissue free was recorded. The jaws were designed for use in parallel-occlusion graspers to avoid the well documented high pinch forces encountered with pivoted occlusion. RESULTS: At all applied forces the force needed to pull tissue from any fenestration design was significantly higher than the force necessary to pull tissue from non-fenestrated jaws (p < 0.05) with no significant differences between the three fenestration designs. The ratio of surface contact to fenestration area must exceed 1:0.4 to achieve a significant increase in the tissue retention. All the profiles studied were made using a single fenestration and with a surface contact to fenestration area ratio of 1:0.8. All such profile designs studied performed significantly better than the control (p < 0.005). The ratio of the mean retraction to applied force across all load conditions tested were 1.23:1.0 and 1.7:1.0 for the waved and toothed profile respectively, with standard deviations for the corresponding retraction force of ±0.45 and ±0.38 respectively. CONCLUSIONS: The retention efficiency of laparoscopic graspers is improved by fenestration which must, however, exceed a certain ratio (>1.0:0.4). Likewise surface profiling of the jaws enhances retention efficiency and its design (tooth, waved, mixed) directly influences the amount of pressure needed to retain tissue.

Mucoadhesive polymer films for tissue retraction in laparoscopic surgery: Ex-vivo study on their mechanical properties.

Safe and effective manipulation of soft tissue during laparoscopic procedures can be achieved by the use of mucoadhesive polymer films. A series of novel adhesive polymer films were formulated in house based on either Carbopol or Chitosan modified systems. The mechanical properties of the polymers and their adherence to bowel were evaluated using ex-vivo pig bowel immersed in 37°C water bath and connected to an Instron tensiometer. Young's modulus was 300 kPa for the Carbopol-polymer and 5 kPa for the Chitosan-polymer. The Chitosan-polymer exhibited much larger shear adhesion than its tensile adhesion: 3.4 N vs. 1.2. Both tensile and shear adhesions contributed to the large retraction force (2.6 N) obtained during l polymer-bowel retraction testing. Work of adhesion at the polymer/serosa interface, defined as the area under the force curve, was 64 mJ, which is appreciably larger than that reported with existing polymers. In conclusion, adhesive polymers can stick to the serosal side of the bowel with an adhesive force, which is sufficient to lift the bowel, providing a lower retraction stress than that caused by laparoscopic grasping which induces high localized pressures on the tissue.

Magnetic retraction of bowel by intraluminal injectable cyanoacrylate-based magnetic glue.

Magnetic retraction offers advantages over physical retraction by graspers because of reduced tissue trauma. The objectives of this study are to investigate a novel method of magnetisation of bowel segments by intraluminal injection of magnetic glue and to demonstrate the feasibility of magnetic retraction of bowel with sufficient force during minimal access surgery. Following an initial materials characterisation study, selected microparticles of stainless steel (SS410- µ Ps) were mixed with chosen cyanoacrylate glue (Loctite 4014). During intraluminal injection of the magnetic glue using ex vivo porcine colonic segments, a magnetic probe placed at the injected site ensured that the SS410-µPs aggregated during glue polymerisation to form an intraluminal mucosally adherent coagulum. The magnetised colonic segments were retracted by magnetic probes (5 and 10 mm) placed external to the bowel wall. A tensiometer was used to record the retraction force. With an injected volume of 2 mL in a particle concentration of 1 g/mL, this technique produced maximal magnetic retraction forces of 2.24 ± 0.23 N and 5.11 ± 0.34 N (n = 20), with use of 5 and 10 mm probes, respectively. The results indicate that the formation of an intraluminal coagulum based on SS410- µPs and Loctite 4014 produces sufficient magnetic retraction for bowel retraction.

Computer use among patients with age-related macular degeneration.

PURPOSE: Age-related macular degeneration (AMD) is the leading cause of incurable vision loss in older adults in industrialized countries and is on a trajectory to disable a growing number of persons as societies age. To assess the potential of using telemedicine for expansion of an in-person AMD self-management program, we examined the extent of computer use in a sample of older adults with AMD. METHODS: 160 older adult volunteers (mean age = 76 years; female = 51%) with AMD (mean visual acuity in better eye: 20/40; worse eye: 20/90) were randomly selected from members of the San Diego County AMD Registry. Computer use was assessed with a Health and Impact Questionnaire. Dependent measures were Snellen visual acuity, National Eye Institute-Visual Function Questionnaire, the AMD Self-Efficacy Questionnaire, and the Geriatric Depression Scale. RESULTS: Overall 70.6% reported computer use at least once per month. By age and gender stratum, 76.5% of men aged 60-74 years, 73.3% of men aged 75 years and over, 74.3% of women aged 60-74 years, and 60.9% of women aged 75 years and over used computers. In logistic regression analyses controlling for age and gender, computer use was associated with better visual acuity (P = 0.029), higher education (P = 0.002), and self-efficacy for communication (P = 0.027). CONCLUSION: The majority of older adults with AMD in our sample used computers, with use highest among more educated and visually intact patients. Computer use to access the Internet is feasible in AMD patients and should be encouraged. The inclusion of computer use in measures of AMD-related functioning appears warranted.

Thermal fusion: effects and interactions of temperature, compression, and duration variables.

BACKGROUND: The constraints imposed by minimal access surgery have driven the need for enabling technologies for thermal vessel occlusion or "tissue welding." The objective of this study was to determine the values of, and interaction between, tissue temperature, apposition force, and clamp time for optimum tissue welding. METHODS: A dedicated experimental device with heated occluding jaws was used for ex vivo experiments on harvested sheep carotid vessels. The device allowed individual variation of temperature (60, 70, 80, and 90 °C), compression force (20, 40, 60, and 80 N) and clamp time (5, 10, 15 s). Weld strength was measured by burst pressure. RESULTS: The best seal quality was obtained at a temperature of 90 °C (p = 0.03), a compression force between 60 and 80 N (p = 0.03), and clamp time of 10 s (p = 0.058). The individual effects of temperature, compression force, and clamp time were all significant at p < 0.001. Although all three were considered to have large effects, clamp time had a reduced effect, relative to temperature and compression force. CONCLUSIONS: Temperature, compression force, and clamp time influence the quality of thermal welding, but the interaction between temperature and apposition force appears to be more dominant.

Comparison of endoscopic task performance with crossed versus uncrossed straight and curved instruments through a single port.

BACKGROUND: Despite advancing technology for single-incision minimal access surgery, there have been no reports on the optimal operating setup and the instruments for use through a single port. This study therefore aimed to compare task performance in single-port surgery between crossed and uncrossed instruments (straight and distally coaxially curved). METHODS: A dedicated trainer box was used to investigate the performance of two tasks (pick-transfer-place and dissection) by 18 surgical residents using two randomly allocated manipulating systems: (1) a conventional, uncrossed manipulation system (UCMS), with surgery through a cone-shaped 40-mm port using coaxially curved or straight instruments subtending a 30° manipulation angle, and (2) a crossed manipulation system (CMS), with surgery through a cylindrical miniport (25 mm) using coaxially curved instruments. RESULTS: The pick-transfer-place task performed with the UCMS enabled comparison between straight and curved coaxial instruments and showed that although the participants moved the same number of objects with either type (p = 0.464), they dropped a significantly more objects with straight instruments (1.5 ± 1.33 vs. 0.61 ± 0.85; p = 0.013). The execution of this task with the CMS (curved instruments only) provided a performance (dropped objects and error rates) equal to that obtained by the UCMS with curved instruments (p = 0.521, p = 0.989). The dissection task with the UCMS showed no difference between straight and curved coaxial instruments in dissection accuracy (75.6 vs. 75.5%; p = 0.950) or execution times (258 vs. 302 s; p = 0.367). The performance of this task by the CMS and the UCMS (with curved coaxial instruments) was equivalent with regard to dissection accuracy (p = 0.849) and execution time (p = 0.402). CONCLUSIONS: Using the UCMS, task performance is better with distally curved coaxial instruments. The CMS (with curved instruments) gives a task performance equivalent to that obtained with UCMS.

Treatment of depression associated with age-related macular degeneration: a double-blind, randomized, controlled study.

BACKGROUND: Depression is frequently found in patients with age-related macular degeneration (AMD). The purpose of this study was to assess the effectiveness of escitalopram in treating major and minor depression in AMD patients. METHODS: We conducted a crossover, randomized, double-blind, placebo-controlled, 16-week study comparing escitalopram with placebo. Inclusion criteria included reduced vision from AMD and major or minor depression, with a 17-item Hamilton Rating Scale for Depression (HAMD-17) score of ≥10. Participants were randomly assigned to receive either escitalopram or placebo for 8 weeks and then crossed over to the other treatment. The primary outcome was change on the total HAMD-17 score with escitalopram treatment compared with placebo. RESULTS: We enrolled 16 AMD patients (mean age 79.1), 12 with major depression and 4 with minor depression. Mean HAMD-17 score at enrollment was 16.1 ± 4.2, and mean visual acuity in the better eye was 20/70. During escitalopram treatment, participants showed a significant reduction in HAMD-17 scores compared with placebo treatment (P = .01). CONCLUSIONS: These findings suggest escitalopram may be an effective treatment for depressive symptoms associated with major or minor depression in AMD patients with vision loss.

Comparison of two actuation systems for laparoscopic surgical manipulators using motion analysis.

BACKGROUND: During surgery, all joints of the upper limbs, including shoulder, elbow, wrist, and finger, coordinate to complete a task. Hence, analysis of these joint movements during surgical manipulations is useful for the design of optimal hand-instrument interface. This study compared two types of surgical handheld manipulators with 6 degrees of freedom with different handle designs: one using a controlling wheel (fingertip control, FTC) and the other with a controlling joint (master slave control, MSC) in terms of ergonomics and movement efficiency. METHODS: Seventeen subjects consisting of surgeons and medical students participated in the experiment. Each performed two standardized surgical tasks in a surgical simulator. A set of reflective markers were attached on the subjects' upper limbs and the marker positions during the tasks were collected by a motion capture system for subsequent analysis of the trunk, shoulder, elbow, wrist, and fingers joint movements. The subjects also completed a Visual Analogue Scale-based questionnaire on their preference for the control mechanism and ease of handling. RESULTS: The data showed that the manipulator with the MSC was more difficult to handle and resulted in larger range of movements, higher velocities, and accelerations in some joints than the manipulator with FTC mechanism. Use of the MSC manipulator also was accompanied by a higher error rate. Additionally, the subjects preferred the finger actuated manipulator and gave it a higher Visual Analogue Score for maneuverability. CONCLUSIONS: The manipulator equipped with the MSC was ergonomically inferior; it was more difficult to handle and provided less precision, resulting in higher error rates than the FTC manipulator. This study also confirmed that motion analysis is useful for assessment of the design of handheld manipulators for endoscopic surgery.

A micropower miniature piezoelectric actuator for implantable middle ear hearing device.

This paper describes the design and development of a small actuator using a miniature piezoelectric stack and a flextensional mechanical amplification structure for an implantable middle ear hearing device (IMEHD). A finite-element method was used in the actuator design. Actuator vibration displacement was measured using a laser vibrometer. Preliminary evaluation of the actuator for an IMEHD was conducted using a temporal bone model. Initial results from one temporal bone study indicated that the actuator was small enough to be implanted within the middle ear cavity, and sufficient stapes displacement can be generated for patients with mild to moderate hearing losses, especially at higher frequency range, by the actuator suspended onto the stapes. There was an insignificant mass-loading effect on normal sound transmission (<3 dB) when the actuator was attached to the stapes and switched off. Improved vibration performance is predicted by more firm attachment. The actuator power consumption and its generated equivalent sound pressure level are also discussed. In conclusion, the actuator has advantages of small size, lightweight, and micropower consumption for potential use as IMHEDs.

Rapid and efficient cell labeling with a MRI contrast agent by electroporation in the presence of protamine sulfate.

AIMS: To investigate various protocols for magnetic labeling of human cancer cells with ferumoxides with a view to developing an effective and fast technique for potential clinical use in MRI. MATERIALS & METHODS: Transfection methods utilizing poly-L-lysine and protamine sulfate (PS), electroporation, and combination of PS with electroporation were evaluated in this in vitro study. RESULTS: Although transfection was more effective in terms of uptake rates (95-100%) and intracellular iron concentrations (4.01-7.34 pg/cell), all transfection agents required prolonged incubation. By contrast, electroporation yielded fast labeling but with a lower efficacy (68-75%, 1.63-2.59 pg/cell). The addition of PS to electroporation increased the labeling efficacy (80-91%, 2.84-4.16 pg/cell) and protected cell viability. This combined method also resulted in the best T(2)*-shortening effect in the in vitro cellular MRI. CONCLUSION: The combined PS-electroporation method provides a fast and efficient protocol for ferumoxide-based cellular imaging and therapeutic procedure.

Ferromagnetization of target tissues by interstitial injection of ferrofluid: formulation and evidence of efficacy for magnetic retraction.

During curative cancer surgery, magnetic retraction could offer advantages over retraction by graspers because of reduced tissue trauma and with the potential for noncontact retraction. To realize magnetic retraction, magnetic fluid was injected into harvested porcine stomachs and an external permanent magnet was used to retract the ferromagnetized tissue. The magnetic forces of four ferrofluids were measured. The results of these experiments showed that iron-oxide-nanoparticle-based ferrofluids do not provide the required retraction force. However, sufficient retraction force is obtained by ferromagnetic microparticles fluids (stainless steel 410, denoted MP-SS410) by virtue of their high magnetization and saturation. In ex vivo surgical retraction experiments, MP-SS410 powder was dispersed in phosphate-buffered saline and other fluids. These ferrofluids were injected into the submucosal layer of harvested porcine stomachs at different concentrations and volumes. The inoculum generated a magnetic retraction force linearly proportional to the concentration and injected volume. Ex vivo surgical retraction, and dissection and resection were possible with a simple magnetic probe. The results of this study indicate that ferromagnetization of tissue can be used to facilitate localized tissue retraction and resection.

Dynamic response to heat--a novel physical characteristic of breast cancer.

We report a novel observation about breast cancer. We imaged 6 fresh pathological specimens of breast cancer (1 mastectomy and 5 lumpectomies) with a sensitive infrared camera. We found that, following exposure to hot air for 1min, the cancers warmed up much less than the surrounding normal breast with a difference ranging from 12 to 20 degrees C. We believe that this physical property of cancer should be explored and may give us better insight into the nature of cancer, its diagnosis (including intraoperative diagnosis) and targeted treatment.

Ametropia, preschoolers' cognitive abilities, and effects of spectacle correction.

OBJECTIVES: To examine cognitive abilities of low-income preschoolers with uncorrected ametropia and effects of spectacle correction. METHODS: Baseline and 6-week data from a longitudinal controlled study were analyzed. Subjects were 70 preschoolers (mean age, 4.6 years; 60.0% were female; and 85.7% were Latino), including 35 children with previously uncorrected ametropia and 35 emmetropic control subjects. Ametropia was defined as bilateral hyperopia of 4.00 diopters (D) or more in children aged 3 to 5 years, astigmatism of 2.00 D or more in children aged 3 years and 1.50 D or more in children aged 4 and 5 years, or a combination of both. Emmetropia was defined as 2.00 sphere diopters or less and 1.00 cylinder diopter or less in both eyes. Ametropes were assessed before and 6 weeks after correction and compared with control subjects. Primary and secondary outcome measures were Beery-Buktenica Developmental Test of Visual-Motor Integration and Wechsler Preschool and Primary Scale of Intelligence-Revised scores, respectively. RESULTS: At baseline, uncorrected ametropes scored significantly lower on the Beery-Buktenica Developmental Test of Visual-Motor Integration (P = .005) and the Wechsler Preschool and Primary Scale of Intelligence-Revised performance scale (P = .01). After 6 weeks of correction, the ametropic group significantly improved on the Beery-Buktenica Developmental Test of Visual-Motor Integration compared with emmetropic control subjects (P = .02). CONCLUSIONS: Preschoolers with uncorrected ametropia had significant reduction in visual-motor function. Wearing spectacles for 6 weeks improved Beery-Buktenica Developmental Test of Visual-Motor Integration scores to emmetropic levels.

Refractive errors in low-income preschoolers.

PURPOSE: To estimate the overall prevalence of refractive errors in a study population of low-income preschoolers in San Diego County. METHODS: The study sample included 507 preschool children selected from a study population of all 3-5 year-old children in Head Start and San Diego Unified School District preschools (74% Latino). The sample was examined by optometrists in the mobile clinic of the University of California, San Diego, Department of Ophthalmology with retinoscopy under cycloplegia to assess the presence of refractive errors defined as myopia >or=2D in 3-4 year-olds and >or=1D in > 4 year-olds; hyperopia >or=4D in 3-4 year-olds and >or=3D in > 4 year-olds; and astigmatism >or=1.75D in 3-4 year-olds and >or=1.5D in > 4 year-olds. Anisometropia was defined as >or=1.25D difference between the eyes. Emmetropia was defined as refractive errors below these levels. RESULTS: A total of 16% (n = 81 children) (95% confidence interval: 15.4-16.5) met study definitions of refractive errors in at least one eye. Myopia was found in 3%, (OD Mean Sphere = 2.4D); hyperopia in 7.5% (OD Mean Sphere = 3.8D); astigmatism in 5.5% (OD Mean Cylinder = 2.3D); and 84% were emmetropic (OD Mean Sphere = 1.3D). CONCLUSIONS: Hyperopia and astigmatism were the most frequent refractive errors in this sample of low-income preschoolers, most of whom were Latino.