Repeatability of Pyramidal Aberrometer Measurements in Keratoconus and Normal Eyes.

PURPOSE: To evaluate the intrasubject repeatability of pyramidal aberrometer measurements in a sample of keratoconus and normal eyes. SETTING: American University of Beirut Medical Center, Beirut, Lebanon. DESIGN: Prospective comparative repeatability analysis. STUDY POPULATION: Keratoconus and Normal eyes from adult patients. OBSERVATION PROCEDURES: Each eye was evaluated with 3 consecutive acquisitions using a pyramidal aberrometer. MAIN OUTCOME MEASURES: The repeatability of different ocular Higher Order and Lower Order Aberrations (HOAs and LOAs, respectively), and Zernike coefficients down to the fifth order, was evaluated. Repeatability was assessed by within-subject standard deviations (Sw), repeatability limits (r), and intraclass correlation coefficients (ICC), among other parameters. RESULTS: 72 keratoconus patients (72 eyes), and 76 normal patients (76 eyes) were included. In normal and keratoconus eyes, the ICC of total LOA and HOAs, as well as each of the Zernike coefficients, was >0.9. The Sw for keratoconus eyes with mean maximal keratometry (Kmax)<50D was 0.1345 for total LOAs, 0.0619 for total HOAs, 0.0292 for horizontal coma, 0.0561 for vertical coma, and 0.0221 for spherical aberration as compared to 0.2696, 0.1486, 0.0972, 0.1497 and 0.0757 for Keratoconus eyes with Kmax>=50D. Similar trend of better repeatability for grade 1 keratoconus and HOA<2D as compared to grade 2 and 3 keratoconus and eyes with HOA>2D were also noted. CONCLUSIONS: Ocular aberrometer measurements generated by high definition pyramidal aberrometers have high repeatability in both normal and mild keratoconus eyes; and moderate repeatability, yet still clinically acceptable, in advanced keratoconus. This is of particular importance in ocular wavefront-guided treatments.

Modified partial Jensen procedure to treat a hypertropic Knobby eye syndrome in a high myopic monocular patient.

We present a case of severe esotropia and hypertropia in a monocular high myope with an inferolateral staphyloma. Surgery was undertaken to secure the inferior rectus to the lateral rectus via a modified partial Jensen technique, along with medial rectus recession successfully improving head and eye positions and ductions.

Ophthalmic injuries from the beirut blast: Managing long-term consequences.

The 2020 Beirut Port explosion was one of the largest non-nuclear urban explosions in history, and resulted in a plethora of oculofacial injuries. In this retrospective study, we present the two year follow up ophthalmic outcomes of the survivors of the blast. Only 16 out of 39 patients continued follow up at our center, with 13 having delayed complications and 7 requiring further surgery. The most common delayed complications related to the eyelid, lacrimal system, and orbit. Treatment of disfiguring facial and peri-ocular scarring with laser-assisted drug delivery of topical 5-fluorouracil showed great promise and significantly improved patients' functional and well as cosmetic outcomes.

Deep Learning-Based Estimation of Implantable Collamer Lens Vault Using Optical Coherence Tomography.

PURPOSE: To develop and validate a deep learning neural network for automated measurement of implantable collamer lens (ICL) vault using anterior segment optical coherence tomography (AS-OCT). DESIGN: Cross-sectional retrospective study. METHODS: A total of 2647 AS-OCT scans were used from 139 eyes of 82 subjects who underwent ICL surgery in 3 different centers. Using transfer learning, a deep learning network was trained and validated for estimating the ICL vault on OCT. A trained operator separately reviewed all OCT scans and measured the central vault using a built-in caliper tool. The model was then separately tested on 191 scans. A Bland-Altman plot was constructed and the mean absolute percentage error (MAPE), mean absolute error (MAE), root mean squared error (RMSE), Pearson correlation coefficient (r), and determination coefficient (R2) were calculated to evaluate the strength and validity of the model. RESULTS: On the test set, the model achieved a MAPE of 3.42%, an MAE of 15.82 µm, a RMSE of 18.85 µm, a Pearson correlation coefficient r of +0.98 (P < .00001), and a coefficient of determination R2 of +0.96. There was no significant difference between the vaults of the test set labeled by the technician vs those estimated by the model: 478 ± 95 µm vs 475 ± 97 µm, respectively, P = .064). CONCLUSIONS: Using transfer learning, our deep learning neural network was able to accurately compute the ICL vault from AS-OCT scans, overcoming the limitations of an imbalanced data set and limited training data. Such an algorithm can assist the postoperative assessment in ICL surgery.

A Comparison of the Long-Term Surgical Outcomes of Horizontal Strabismus Surgery between Resident Clinic and Private Clinic Patients.

PURPOSE: To compare the long-term surgical outcomes of patients with horizontal strabismus whose surgery was performed in an outpatient department (OPD) setting (by residents-in-training) to those whose surgery was performed in a private clinic (PC) setting (by staff-ophthalmologists) in the same operating room/institution. METHODS: Two hundred and forty-four patients' charts who had horizontal strabismus surgeries from January 2007 to 2020 were reviewed retrospectively. A total of 92 patients were operated on by residents and followed in OPD, and 152 patients by staff-surgeons and followed in PC. Demographic data and eye exam parameters were collected. Distance and near deviation (in prism diopters, PD) were extracted and compared between groups at baseline and postoperatively (6 months and yearly for up to 6 years). Success was defined as a postoperative motor alignment of 10PD or less. RESULTS: The mean age of the 244 patients was 10.5 ± 11.7 years, with no significant differences between groups. A longer follow-up duration was reported in the PC group (34.9 ± 24.3 months vs 25.3 ± 20.2 months). Patients had similar success rates in both groups in the early postoperative period (6 months and 1 year); however, a higher success rate was observed in the PC group compared to OPD at 3, 5 and 6 years with the following respective values: 72.2% vs 50% (p < .001), 75% vs. 66.7% (p = .02), and 68.6% vs. 66.7% (p = .03). The difference was more pronounced in the esotropia subgroup mostly at 3 years follow-up. CONCLUSION: This study showed a similar success rate of horizontal strabismus surgery performed in a PC setting by staff surgeons as compared to that performed in an OPD setting by residents at 6 months and 1 year. A significantly higher success rate was observed at long term follow-up (after 2 years) in the PC group compared to the OPD group, possibly related to the difference in compliance with post-operative follow-up management and not to surgery itself.

Characteristics and long-term surgical outcomes of horizontal strabismus.

PURPOSE: Our aim was to report the characteristics and long-term surgical outcomes of three subgroups of horizontal strabismus in a single institution (divided by strabismus subtype) in a developing country and look into pre-operative factors predictive of surgical success. METHODS: Two hundred and forty-four complete charts of patients, divided into 152 esotropes (ET) and 92 exotropes (XT) who had undergone horizontal strabismus surgeries, were retrospectively reviewed. Charts of patients with muscle palsy, Duane syndrome and consecutive strabismus were excluded; 172 patients were included divided into partially accommodative ET, congenital ET and intermittent XT. Surgical success was defined as a post-operative angle deviation of 12 prism diopters or less. RESULTS: The mean follow-up period of all patients was 31.64 ± 23.12 months. The subgroups were divided into partially accommodative ET (60 patients), congenital ET (60 patients), and intermittent XT (52 patients). Esotropes (both partially accommodative and congenital) presented earlier (p < 0.001). Also, partially accommodative ET had a significantly higher spherical equivalent (SE) compared to congenital ET patients, who had a higher SE than intermittent XT (p < 0.001). Congenital ET patients had a significantly larger angle of deviation (for both far and near) than both partially accommodative ET and intermittent XT patients (p < 0.001). The overall success rate was 72.67% for the whole group with no significant differences among subgroups. Success rate of partially accommodative ET surgery was 78.33% compared to that of congenital ET at 66.67% and intermittent XT at 73.07%. Significant post-operative improvement in sensory fusion was observed mainly for patients with partially accommodative esotropia and intermittent exotropia. CONCLUSION: Our results showed that esotropes (both partially accommodative and congenital) presented earlier, with a higher spherical equivalent in the partially accommodative ET subgroup, while the congenital ET subgroup had the largest angle of deviation for both distance and near. The overall surgical success rate for horizontal strabismus surgery was 72.67% with the 3 subgroups having similar success rates. A younger age at presentation and absence of amblyopia were positively correlated with surgical success in the partially accommodative esotropia group.

Ophthalmic Injuries After the Port of Beirut Blast-One of Largest Nonnuclear Explosions in History.

IMPORTANCE: A review of the injury patterns, treatment strategies, and responding physicians' experience during the Port of Beirut blast may help guide future ophthalmic disaster response plans. OBJECTIVE: To present the ophthalmic injuries and difficulties encountered as a result of the Port of Beirut blast on August 4, 2020. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review of all patients who presented to the emergency department and 13 ophthalmology outpatient clinics at the American University of Beirut Medical Center for treatment of ophthalmic injuries sustained from the explosion in Port of Beirut, Beirut, Lebanon, from August 4 to the end of November 2020. Patients were identified from emergency records, outpatient records, and operative reports. MAIN OUTCOMES AND MEASURES: Types of ocular injuries, final best-corrected visual acuity, and need for surgical intervention were evaluated. Visual acuity was measured with correction based on noncycloplegic refraction using the Snellen medical record. EXPOSURES: Ocular or ocular adnexal injuries sustained from the Port of Beirut explosion. RESULTS: A total of 39 blast survivors with ocular injuries were included in this study. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to the ophthalmology clinics for a total of 48 eyes of 39 patients were treated secondary to the blast. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, more than half of which were urgently requested on the same day of presentation (14 [35.9%]). Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26 [54.2%]), eyelid lacerations (20 [41.6%]), orbital fractures (14 [29.2%]), brow lacerations (10 [20.8%]), hyphema (9 [18.8%]), open globe injuries (10 [20.8%]), and other global injuries. Only 7 injured eyes (14.5%) had a final best-corrected visual acuity of less than 20/200, including all 4 open globe injuries with primary no light perception (8.3%) requiring enucleation or evisceration. CONCLUSIONS AND RELEVANCE: In the aftermath of the Port of Beirut explosion, a review of the ophthalmic injuries showed a predominance of shrapnel-based injuries, many of which had a delayed presentation owing to the strain placed on health care services. Reverting to basic approaches was necessary in the context of a malfunctioning electronic medical record system.

A Global Assessment of Eye Health and Quality of Life: A Systematic Review of Systematic Reviews.

IMPORTANCE: More than 1 billion people worldwide have vision impairment or blindness from potentially preventable or correctable causes. Quality of life, an important measure of physical, emotional, and social well-being, appears to be negatively associated with vision impairment, and increasingly, ophthalmic interventions are being assessed for their association with quality of life. OBJECTIVE: To examine the association between vision impairment or eye disease and quality of life, and the outcome of ophthalmic interventions on quality of life globally and across the life span, through an umbrella review or systematic review of systematic reviews. EVIDENCE REVIEW: The electronic databases MEDLINE, Ovid, Embase, Cochrane Database of Systematic Reviews, Proquest Dissertations, and Theses Global were searched from inception through June 29, 2020, using a comprehensive search strategy. Systematic reviews addressing vision impairment, eye disease, or ophthalmic interventions and quantitatively or qualitatively assessing health-related, vision-related, or disease-specific quality of life were included. Article screening, quality appraisal, and data extraction were performed by 4 reviewers working independently and in duplicate. The Joanna Briggs Institute critical appraisal and data extraction forms for umbrella reviews were used. FINDINGS: Nine systematic reviews evaluated the association between quality of life and vision impairment, age-related macular degeneration, glaucoma, diabetic retinopathy, or mendelian eye conditions (including retinitis pigmentosa). Of these, 5 were reviews of quantitative observational studies, 3 were reviews of qualitative studies, and 1 was a review of qualitative and quantitative studies. All found an association between vision impairment and lower quality of life. Sixty systematic reviews addressed at least 1 ophthalmic intervention in association with quality of life. Overall, 33 unique interventions were investigated, of which 25 were found to improve quality of life compared with baseline measurements or a group receiving no intervention. These interventions included timely cataract surgery, anti-vascular endothelial growth factor therapy for age-related macular degeneration, and macular edema. CONCLUSIONS AND RELEVANCE: There is a consistent association between vision impairment, eye diseases, and reduced quality of life. These findings support pursuing ophthalmic interventions, such as timely cataract surgery and anti-vascular endothelial growth factor therapy, for common retinal diseases, where indicated, to improve quality of life for millions of people globally each year.

Eye health and quality of life: an umbrella review protocol.

INTRODUCTION: Vision impairment and eye disease are major global health concerns and have been associated with increased morbidity and mortality, and lower quality of life. Quality of life, whether generic, vision-specific or disease-specific, is an important measure of the impact of eye health on people's daily activities, well-being and visual function, and is increasingly used to evaluate the impact of ophthalmic interventions and new devices. While many studies and reviews have examined the relationship between vision or eye health and quality of life across different contexts, there has yet to be a synthesis of the impact of vision impairment, eye disease and ophthalmic interventions on quality of life globally and across the lifespan. METHODS AND ANALYSIS: An umbrella review of systematic reviews will be conducted to address these two questions: (1) What is the association of vision impairment and eye disease with quality of life? (2) What is the impact of ophthalmic interventions on quality of life? A search of related literature will be performed on the 11 February 2020 in Medline Ovid, Embase.com, Cochrane Database of Systematic Reviews, Proquest Dissertations and Theses Global, and the grey literature, and repeated at the synthesis stage. Title/abstract and full-text screening, methodological quality assessment and data extraction will be conducted by reviewers working independently and in duplicate. Assessment of methodological quality and data extraction will be performed using Joanna Briggs Institute standard forms. Findings from the systematic reviews and their methodological quality will be summarised qualitatively in the text and using tables. ETHICS AND DISSEMINATION: No ethical approval is required. Results of this umbrella review will be published in a peer-reviewed journal and summarised in the Lancet Global Health Commission on Global Eye Health. TRIAL REGISTRATION NUMBER: This protocol was registered in the Open Science Framework Registries (https://osf.io/qhv9g/).

Targeted educational program improves infant positioning practice in the NICU.

QUALITY PROBLEM OR ISSUE: Infant positioning may interfere with neuromotor development. Bedside education and Infant Positioning Assessment Tool (IPAT) improve nurses' and doctors' proficiency in applying proper infant positioning. INITIAL ASSESSMENT: Nursing compliance with proper positioning is suboptimal due to many factors. One factor was the inadequate knowledge and practice of infant positioning, since the baseline mean IPAT score was 3.4. CHOICE OF SOLUTION: Three experienced neonatal intensive care unit (NICU) nurses were chosen as position champions to help other NICU nurses apply proper positioning and monitor IPAT scores. Education and hands-on demonstration sessions were developed based on the observed baseline practice. IMPLEMENTATION: Periodic education with hands-on demonstration was given to NICU nurses and residents. Infants' positions were objectively scored using IPAT. Two Plan, Do, Study and Act cycles were completed and adjustments were made based on each cycle's achieved results. EVALUATION: Mean IPAT scores increased from 3.4 at baseline and 6.3 in the second cycle to 7.3 in the third cycle of intervention. LESSONS LEARNED: A systematic approach targeting infants' positioning succeeded in improving nurses' and residents' clinical performance. Not reaching significant change until after 18 months highlights the difficulty and complexity in changing behaviors.

Structured Educational Intervention Leads to Better Infant Positioning in the NICU.

PURPOSE: The purpose is to test the effectiveness of an educational intervention in improving infant positioning because positioning may interfere with neuromotor development. METHODS: A quality improvement (QI) project was initiated to increase knowledge and improve the compliance of nurses and physicians in infant positioning using the Infant Positioning Assessment Tool (IPAT). The project was part of Neonatal Individualized Developmental Care Assessment Program (NIDCAP) training. It included informal discussion and practice about infant positions. MAIN OUTCOME VARIABLES: Staff knowledge, IPAT score. RESULTS: Fifty-two pediatric residents and 39 NICU nurses participated in this project. The mean knowledge assessment test score improved significantly for both nurses (p < .0001) and residents (p < .0001) postintervention; IPAT scores increased significantly from 3.4 (±2. 5) to 8.1 (±2.7) (p < .001). CONCLUSION: Nurses' education with hands-on practice improved infant positioning in the NICU; this may lead to fewer positional deformities and possibly an improved developmental outcome.