Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape.

Vernal keratoconjunctivitis (VKC) is a chronic, progressive, and potentially sight-threatening form of ocular inflammatory disease that primarily affects children and young adults. Prevalence varies by region, ranging from <2 per 10,000 in the United States to as high as 1,100 per 10,000 in parts of Africa. The rarity of VKC in developed countries can make differential diagnosis challenging, and treatment is often delayed until the disease is advanced, and symptoms are significantly impacting patients' quality of life. Although once viewed primarily as an immunoglobulin E-mediated condition, approximately 50% of patients with VKC do not exhibit allergic sensitization. It is now recognized that the immunopathology of VKC involves multiple inflammatory pathways that lead to the signs, symptoms, and conjunctival eosinophilic and fibroproliferative lesions that are a hallmark of the disease. We examine the evolution of our understanding of the immunopathology of VKC, the expanding VKC treatment armamentarium, the clinical implications of emerging treatment approaches, and future directions for VKC research and practice.

Early Experience With Full-scope Shared-care Teleglaucoma in Canada.

PRCIS: Large Canadian full-scope, shared-care teleglaucoma facilitates efficient management and diversion of medically stable patients away from overburdened subspecialty clinics while allowing patients the convenience of shorter travel, shorter wait time, and continuity with one provider. This report shares Care1 protocol, early patient characteristics, and quality data. PURPOSE: This paper describes early experience with Care1, a large full-scope, shared-care teleglaucoma program. Optometrists located in high-demand locations saw patients in-person, acquired clinical history, performed a physical examination, organized diagnostic testing, then uploaded data to a proprietary online platform where they were able to collaborate with participating ophthalmologists to make plans for patient care. MATERIALS AND METHODS: The Care1 database was queried for all patients with a diagnosis of glaucoma or glaucoma suspect seen between February 2016 and March 2017. Clinical characteristics like diagnosis, ocular medication history, best-corrected visual acuity, intraocular pressure, cup-to-disc ratios, optical coherence tomography imaging results, and central corneal thickness were collected. Quality metrics studied included rates of referral to an in-person ophthalmologist and consistency of cup-to-disc assessments between in-person optometrists and remote ophthalmologists. RESULTS: A total of 4070 patients received care at a Care1 teleophthalmology site in 2 provinces for glaucoma assessment from February 2016 to March 2017. The population was 55.1% female, and the average age was 57.8 years. Overall, 97.3% of patients had a best-corrected visual acuity between 20/20 and 20/40 and 3.3% had an intraocular pressure >26. An in-person consultation with an ophthalmologist was recommended for 1.9% of patients. CONCLUSION: Early experience with this full-scope, shared-care teleglaucoma program in Canada indicates it is a convenient, collaborative model of care for glaucoma suspects, and medically stable glaucoma patients.

Reducing discomfort of eye drops prior to retinal examination in the neonatal intensive care unit.

OBJECTIVE: To evaluate the effectiveness in reducing pain by giving oral sucrose and non-pharmacological comfort measures prior to topical administration of mydriatic eye drops on premature infants undergoing retinopathy of prematurity (ROP) screening eye exams in a neonatal intensive care unit (NICU). STUDY DESIGN: A prospective quality improvement study was conducted in the NICU where infants were given oral sucrose prior to administration of mydriatic eye drops while a second person performed facilitated tucking and containment. Premature Infant Pain Profile (PIPP) scores were recorded during eye drop administration and compared to a group that did not receive any comfort measures. RESULT: Sixty-eight infants were enrolled. Mean PIPP scores increased an average of 1.5 (SD = 1.5) during administration of mydriatic drops without comfort measures compared to 0.6 (SD = 0.8) when comfort measures were used. This difference was statistically significant (p < 0.001). CONCLUSIONS: Oral sucrose and simple comfort measures can be effective in reducing pain associated with mydriatic eye drops.

The terrible truth about toppling televisions.

OBJECTIVE: To determine the profile of children's injuries resulting from television tipovers and to evaluate the potential in a paediatric health centre for television sets to be tipped by young children. DESIGN: The present study was conducted by case report review, a retrospective audit of a regional subset of the Canadian Hospitals Injury Reporting and Prevention Program database, and prospective testing of all child-accessible television sets for potential tipping using a static model of a climbing child. SETTING: Children attending the emergency department of a regional paediatric health centre who reported injuries resulting from a television tipover to the Canadian Hospitals Injury Reporting and Prevention Program were studied. All child-accessible television sets within the same regional paediatric health centre were included in the study. MAIN OUTCOME MEASURES: The main study outcome measures were the demographics and profile of television tipover injuries encountered, and the failure rate of child-accessible televisions to maintain stability when tested using a static model of a climbing child (four years of age at the 90th weight percentile). RESULTS: At least 104 children reported injuries related to televisions tipovers between 1990 and 2002. The majority occurred in two-to four-year-old children, and 61% occurred in boys. The most common areas to be injured were the head and neck. Within the hospital, 90% of child-accessible televisions were tippable by children four years of age or younger. CONCLUSIONS: Television tipovers have the potential to cause significant childhood injuries. Because television sets were not safely maintained within one paediatric health centre, one can only speculate about television safety in homes. Parents need to be educated about this injury risk, and standards for the anchoring of televisions are needed.

The natural history of surgically untreated intermittent exotropia-looking into the distant future.

PURPOSE: We studied patients with distance intermittent exotropia with at least 5 years follow-up before any surgical therapy, to determine how often amblyopia developed, whether there was progressive worsening in the angle or control of the exodeviation, whether there was deterioration in binocular vision, and other parameters. METHODS: Retrospective review of charts of patients with exodeviations examined consecutively over 17 years. RESULTS: There were 109 patients followed for a mean of 9 years (range 5 to 25). Amblyopia was mild (20/25 in 33, 20/30 in 15, and 20/40 in 2). There was no significant change in the mean exoangle from initial to final visit (20.6 to 20.9 PD), but the initial to final exoangle decreased by more than 10 PD in 19%, remained stable in 58%, and increased by more than 10 PD in 23%. There was no statistically significant trend for worsening or improving when serial measurements were plotted and the aggregate slopes were analyzed. Change in control in the distance from initial to final visit was favorable in 26%, showed no change in 51%, and was unfavorable in 23%, with 17% deteriorating to a constant distance exotropia. Mean near stereoacuity at the final visit was 88 seconds of arc. Strabismus surgery was performed in 14% of patients from 5 to 18 years (mean 9) after their initial visit. CONCLUSIONS: Visual acuity and near stereoacuity were generally good. There was little change in the mean angle of deviation from initial to final visit for the group, with a nearly chance occurrence for the distance deviation to progressively worsen or improve, perhaps explaining why strabismologists have had difficulty definitively prognosticating about the long-term stability of intermittent exotropia.