Predictive performance of corneal and lid margin sensitivity for dry eye disease: An investigator-masked, prospective, prognostic accuracy study.

PURPOSE: To evaluate the prognostic ability of non-contact esthesiometry corneal and lid margin sensitivity measurements in detecting symptoms and signs of dry eye disease, as defined by the global consensus TFOS DEWS II criteria. METHODS: A total of 87 community residents (58 females; mean ± SD age, 53 ± 16 years) were recruited in an investigator-masked, prospective, prognostic accuracy study. Dry eye symptomology, tear film parameters, and ocular surface characteristics were evaluated in a single clinical session, and non-contact esthesiometry corneal and lid margin sensitivity measurements performed by an independent masked assessor. RESULTS: Overall, 49 (56%) participants fulfilled the TFOS DEWS II criteria for dry eye disease, while 57 (66%) exhibited clinical symptoms, and 67 (77%) had positive signs. The prognostic abilities of corneal and lid margin sensitivity measurements were significantly greater than chance for the detection dry eye signs (both p ≤ 0.03), but not for symptoms or overall disease diagnosis (all p > 0.10). The Youden-optimal prognostic cut-offs for corneal and lid margin sensitivity thresholds were both ≥0.8 mbar for the detection of clinical dry eye signs. Lid margin sensitivity demonstrated marginally higher predictive performance than corneal sensitivity (C-statistic, 0.688 versus 0.658), and was significantly correlated with tear film stability, corneal, conjunctival and lid wiper staining (all p < 0.05). CONCLUSIONS: Corneal and lid margin sensitivity demonstrated moderate prognostic utility for detecting clinical dry eye signs. Future research is warranted to investigate the utility of incorporating non-contact esthesiometry in the workup for dry eye disease and neurotrophic keratopathy.

Cost awareness amongst irish ophthalmologists.

BACKGROUND: Healthcare systems have increasingly limited and stretched budgets. Clinicians have a key role in budget allocation. Awareness of the costs of high-use clinical items is important. AIMS: Assess awareness of the cost of commonly utilised clinical items amongst Irish Ophthalmologists METHODS: Irish ophthalmologists were contacted and asked to fill out an anonymous survey. We assessed knowledge of hospital costs of surgical materials, medications and anti VEGF drugs as well as retail pharmacy costs of commonly prescribed medications. The cost of items to the hospital was recorded from pharmacy and ward order receipts from a single university hospital. The costs of items to the patient were calculated by taking an average of 3 prices charged by local retail pharmacies. For each estimate we calculated the absolute error from the true price. We calculated the mean absolute errors (MAE) and percentage errors (MAPE) across the different groups. RESULTS: We received responses from 47 participants (15 Senior House Officers, 11 Registrars, 21 Consultant/Community Ophthalmologists). Despite 70% of respondents agreeing that the cost of an item should have a major role in its use, the average estimate was 124% inaccurate. Less than 50% of responses were within 50% of the true cost of the item. Self-perceived knowledge was acknowledged to be limited or very limited in 73% of responses. CONCLUSIONS: We demonstrate variable and limited levels of cost awareness. Seniority and better self-perceived knowledge were not found to be associated with better estimate accuracy.

Management of Keratoconus in Down Syndrome and Other Intellectual Disability.

PURPOSE: The purpose of this study was to assess an intellectual disability (ID) cohort with keratoconus (KC) regarding ophthalmic (visual acuity and corneal tomography) and systemic characteristics and to describe an appropriate clinical algorithm for investigation and management of KC in this setting. METHODS: This was the retrospective cohort study of patients with ID (Down syndrome, autism, and other) in the cornea department of a tertiary referral ophthalmic hospital in Dublin, Ireland. Retrospective chart review was conducted on people with ID undergoing examination under anesthesia or crosslinking under general anesthetic. Key outcome data included corneal examination findings, corneal tomography, visual acuity, and examination findings (eg, type of ID, general anesthetic, and cardiac status). RESULTS: Mean age of the 24 patients was 31.9 years (66.7% male). ID type was Down syndrome (66.7%), autism (25%), and other (8.3%). KC was diagnosed in 98% of eyes, with 45.8% having untreatable advanced disease (57.1% of these bilateral), 39.6% amenable to corneal collagen crosslinking (35.7% of these bilateral), and 6.3% having corneal transplantation. Congenital heart defects were present in 37.5% of the Down syndrome group. There were no serious ocular or systemic adverse events. CONCLUSIONS: KC is strikingly prevalent in the ID population. Ireland has the highest rate of Down syndrome in Europe (26.3:10,000 live births). This group is rarely suitable for corneal transplantation, and corneal collagen crosslinking is an effective intervention to prevent progression to advanced KC in this already socially restricted group. We propose an algorithm for investigation/treatment and also recommend uniform pediatric KC screening/treatment in ID populations.

Analyzing the Carbon Footprint of an Intravitreal Injection.

PURPOSE: To estimate the carbon footprint of a single intravitreal injection in a hospital-based intravitreal service. METHODS: Greenhouse gas emissions attributable to the delivery of an intravitreal injection were calculated using a hybrid lifecycle analysis technique. Data were collected regarding procurement of materials, patient travel, and building energy use. RESULTS: Carbon emissions associated with a single intravitreal injection, excluding the anti-VEGF agent, were 13.68 kg CO 2 eq. This equates to 82,100 kg CO 2 eq annually for our service. Patient travel accounted for the majority of emissions at 77%, with procurement accounting 19% for and building energy usage for 4% of total emissions. The omission of items considered dispensable from injection packs would reduce carbon emissions by an estimated 0.56 kg per injection - an annual saving of 3,360 kg CO 2 eq for our service. Similar savings, if extrapolated to a country the size of the United Kingdom, could yield annual carbon savings of 450,000 kg CO 2 eq. For context, a single one-way economy transatlantic flight produces 480 kg CO 2 eq per person. CONCLUSION: Wasteful practice in healthcare increases greenhouse gas production and drives climate change. The healthcare sector should be a leader in sustainable practice promotion and changes to high volume procedures have the largest impact on emissions. Long-acting agents offer the greatest future potential for meaningful reductions.

Presentation of Infectious Keratitis to ED during COVID-19 Lockdown.

OBJECTIVES: To compare presentation of infectious keratitis during COVID-19 lockdown with previous years, assess relative severity, and compare outcomes between COVID-19 and pre-COVID-19 era groups. METHODS: Acute presentations of infectious keratitis during a strict government-mandated COVID-19 lockdown period were analysed retrospectively (March-May 2020). Data were compared with the same periods in 2018-2019. The clinical notes of patients undergoing corneal scrapes were reviewed, and data were collected on treatment, culture growth, surgical interventions, visual outcomes, admission rates, and risk factors. RESULTS: There were 37% fewer presentations of infectious keratitis to the ED in 2020 (N = 29, 47, and 45, respectively). Risk factor profiles and microbial data were similar across all periods. Admission rates and use of fortified antibiotics were lower in 2020. COVID-19 era cases recovered less vision (LogMAR 0.26, 0.67, and 0.45, respectively; p = 0.04) and were more likely to require surgical intervention (10%, 4%, and 2%, respectively; OR 3.4 (CI 0.7-17.9, p = 0.1)). CONCLUSION: A concerning fall in presentations of infectious keratitis to ED during the pandemic lockdown was observed. Though societal behaviour changed during the lockdown, our data suggest it is unlikely that the incidence of infectious keratitis fell significantly. It is unclear how and where these patients were treated. We postulate that lower levels of visual recovery and higher rates of surgical intervention may have been caused by delays in accessing care. To minimise avoidable ocular morbidity as COVID-19 resurges, we must communicate clearly with patients and health professionals on how to access available emergency eye care services.

Management of orbital conjunctival epithelial inclusion cyst using trichloroacetic acid (20%) in an outpatient setting.

Conjunctival epithelial inclusion cysts are an infrequent complication in anophthalmic sockets. The ocular prosthesis may become difficult to retain or it may cause local discomfort. Treatment options described include surgical resection, marsupialisation, and the use of injected sclerosing agents. We present a case of a 27-year-old female who developed a conjunctival epithelial inclusion cyst two years after a left eye evisceration. This invariably caused the ocular prosthesis to become cosmetically unacceptable. Trichloroacetic acid 20% (TCA) was injected intracystically as a minor procedure at the slit lamp. Four months later there was no recurrence of the cyst and the prosthesis retained an excellent position in the socket. This case highlights the successful treatment of a conjunctival epithelial inclusion cyst with TCA (20%) without the need for a surgical procedure.

Safety and Efficacy of Supratarsal Triamcinolone for Treatment of Vernal Keratoconjunctivitis in Ireland.

PURPOSE: To describe the clinical features, risk factors, and treatment outcomes after supratarsal injection of triamcinolone for vernal keratoconjunctivitis (VKC). METHODS: A retrospective review of all patients treated with supratarsal triamcinolone for VKC between February 2002 and May 2017 at the Royal Victoria Eye and Ear Hospital and Our Lady's Children Hospital Crumlin, Dublin, Ireland, was performed. RESULTS: Twenty-five patients, 46 eyes, and 145 injections were included for analysis. The mean age at first injection was 9.1 ± 5.7 years. Ninety-six percent of the patients were male. A seasonal variation was noted, with 59 injections (41%) of triamcinolone administered for acute and refractive cases of VKC in the summer compared with 35 (24%), 35 (24%), and 16 (11%) in the spring, autumn, and winter months, respectively. The most common presenting complaint was red eye, which was seen in all cases. Hay fever (64%) was the most common associated systemic disease. Each eye required, on average, 3.2 injections (range 1-9 injections), and the mean duration from the onset of symptoms to final treatment was 3.03 years (range 0-7.9 years). The mean presenting and final visual acuities were 0.33 and 0.11 logarithm of the minimum angle of resolution, respectively (P < 0.0001). During our study period, no patient experienced intraocular pressure rise requiring treatment, development of lenticular opacity, or ptosis after supratarsal injection of triamcinolone. CONCLUSIONS: In this case series, supratarsal triamcinolone was used in cases of VKC in which topical medications had failed to control the disease process. All patients reported improvement after treatment. There were no cases of intraocular pressure rise, lenticular opacity, or ptosis development after treatment.

Secukinumab-Associated Crystalline Corneal Deposition.

PURPOSE: To describe the first reported case of corneal crystalline deposition associated with the monoclonal antibody secukinumab (Cosentyx; Novartis, Basel, Switzerland) and the subsequent follow-up of the case. METHODS: Case report. RESULTS: An 18-year-old man was referred for a corneal opinion 1 year after commencing secukinumab monoclonal antibody therapy for ankylosing spondylitis. Crystalline corneal deposits were identified at a routine optometrist appointment. The same optometrist had documented normal anterior segment examination 2 years earlier. On examination, anterior stromal refractile crystals were visible in both corneas extending out to the limbus. The patient's best-corrected distance visual acuity was 20/20 bilaterally, and he was asymptomatic. Family history and systemic workup for other causes of crystal deposition were negative. By a process of elimination of other etiologies, we concluded that the monoclonal antibody secukinumab was responsible for the deposition. At the 1-year point of treatment with secukinumab, the patient remains asymptomatic and is still undergoing therapy. CONCLUSIONS: To the best of the authors' knowledge, this is the first report of corneal crystal deposition attributed to secukinumab. The number of monoclonal antibodies in use across multiple medical disciplines is increasing, and corneal specialists may see this presentation more frequently in the future. These drugs provide critical disease-modifying treatment to patients with debilitating systemic pathology. It is important that we understand the natural history of their side effects to allow their full utilization.

Maximising Refractive Outcomes with an Extended Depth of Focus IOL.

OBJECTIVE: To assess the impact of the magnitude of preoperative and postoperative corneal astigmatism on refractive outcomes in patients undergoing cataract surgery or lens exchange with an extended depth of focus intraocular lens. To compare visual outcomes of steep and temporal on-axis corneal incisions. SETTING: Department of Ophthalmology, Blackrock Clinic, Dublin, Ireland. DESIGN: Prospective cohort analysis. METHODS: Fifty-three consecutive adult patients (94 eyes) undergoing routine phacoemulsification with Symfony IOL implantation were analysed. Exclusion criteria: targets for mini-monovision, incomplete data, other ocular pathology. Data were prospectively collected on pre- and postoperative refraction, keratometry, distance vision, near vision, surgical wound site and Surgically Induced Astigmatism (SIA). RESULTS: The average postoperative monocular Uncorrected Distance and Near visual acuities (UDVA and UNVA) were 0.12 LogMAR (± 0.1) (6/7.5+1) and 0.34 LogMAR (± 0.09) respectively. The average binocular UDVA and UNVA were 0.05 (± 0.07) and 0.29 LogMAR (± 0.06) respectively. Low levels of preoperative corneal astigmatism (0-0.99 D) were associated with better LogMAR UDVA and UNVA when compared with higher levels (> 0.99 D): 0.11 (CI 0.103-0.107) vs. 0.206 (CI 0.122-0.290) (p =0.015, CI 95%) and 0.33 (CI 0.316 - 0.356) vs. 0.39 (CI 0.34-0.43) (p =0.034, CI 95%) respectively. When patients with steep on-axis corneal incisions were compared with temporal on-axis corneal incisions, no difference was detected in visual outcome or SIA. CONCLUSION: The Symfony IOL is an effective surgical means of addressing presbyopia and reducing postoperative spectacle dependence. We stress caution when offering potential spectacle independence for patients with over 1D of preoperative corneal astigmatism as these patients achieve statistically significantly inferior and less predictable visual results.

The Impact of Strabismus Surgery on Irish Adults.

AIMS: Our primary objective was to evaluate our adult strabismus service and the impact strabismus surgery has on quality of life (QOL) in patients from an Irish cohort. Our secondary objective was to compare QOL outcomes across different subgroups. METHODS: A service evaluation was prospectively performed over an 18-month period. We prospectively audited the preoperative and postoperative QOL scores from 35 adult strabismus procedures using the adult strabismus score (AS-20) (0-100). RESULTS: Postoperative patients achieved an average 14.22 score increase in QOL (p = 0.0018). Females showed lower preoperative scores (46.78 vs. 60.89; p = 0.047) and a trend towards larger increases compared to males (21.05 vs. 51.12; p = 0.1). No significant difference was detected between primary and recurrent strabismus repairs (18.10 vs. 16.55; p = 0.4). Lower preoperative scores (0-33) were associated with higher increases compared with moderate (34-66) and high (67-100) preoperative scores (33.47, 12.03, -4.57 respectively). Patients reporting QOL score decreases after surgery were more likely to come from the high preoperative score group than the moderate or low groups (50%, 19% and 22% respectively). CONCLUSION: We demonstrate that strabismus surgery has a significant positive impact on QOL scores in Irish adults. We show that patients with high preoperative QOL scores may have a greater chance of QOL score decreases postoperatively, despite good clinical alignment. We believe greater preoperative discussion around patient expectations in these cases, may improve subjective postoperative results.

Self-assembled uracil complexes containing tautomeric uracils: an IRMPD spectroscopic and computation study of the structures of gaseous uracilnCa2+ (n = 4, 5, or 6) complexes.

The structures of doubly-charged uracil (U) complexes with Ca2+, UnCa2+ (n = 4, 5, 6), were studied by infrared multiple photon dissociation (IRMPD) spectroscopy and computational methods. The ions were produced by electrospray ionization (ESI) and were isolated in the gas phase in a Fourier-transform ion cyclotron resonance mass spectrometer (FT-ICR-MS). The recorded IRMPD spectra in both the fingerprint and the C-H/N-H/O-H stretching regions, combined with computed vibrational spectra, reveal that the structures present in the greatest abundance consist of both canonical uracil as well as the lactam (or colloquially "enol") tautomer of uracil. U4Ca2+ consists of two hydrogen-bonded dimers of uracil, one canonical and one tautomer, with each uracil interacting with Ca2+ through a carbonyl oxygen. The structures most consistent with the vibrational spectrum of U6Ca2+ consist of two hydrogen-bonded uracil trimers, each composed of two canonical and one enolic uracil, with each uracil also interacting with Ca2+ through carbonyl oxygen. U5Ca2+ consists of one of the aforementioned trimers and dimers, each containing one enol tautomerized uracil. The computed structures whose vibrational spectra best agree with the experimental vibrational spectra are also the lowest-energy structures for all three complexes. This study clearly shows that some uracils adopt the normally very high energy enol tautomer in the lowest energy gas phase complexes of uracil with a doubly-charged ion like Ca2+.

Ammoniated Complexes of Uracil and Transition Metal Ions: Structures of [M(Ura-H)(Ura)(NH3)]+ by IRMPD Spectroscopy and Computational Methods (M = Fe, Co, Ni, Cu, Zn, Cd).

The structures of deprotonated d-block metal dication bound uracil dimers, solvated by a single ammonia molecule, were explored in the gas phase using infrared multiple photon dissociation (IRMPD) spectroscopy in a Fourier transform ion cyclotron resonance-mass spectrometer. The IRMPD spectra were then compared with computed IR spectra for various isomers. Calculations were performed using B3LYP with the 6-31+G(d,p) basis set for all atoms, with the exception of Cd, for which the LANL2DZ basis set with relativistic core potentials was used. The calculations were then repeated using the def2-TZVPP basis set on all atoms and were compared to the first set of calculations. The lowest-energy structures are those in which one uracil is deprotonated at the N3 position and, aside from the Cu complex, the intact uracil is a tautomer in which the N3 hydrogen is at the O4 carbonyl oxygen. The metal displays a tetradentate interaction to the uracil moieties, with the exception of Cu, which is tridentate, and the ammonia molecule is bound directly to the metal center. In the Cu complex, a square planar geometry is observed about the metal center, consistent with Jahn-Teller distortions commonly observed in Cu(II) complexes, and the intact uracil assumes its canonical tautomer. All other metal cation complexes are five-coordinate, square pyramidal complexes, with the intact uracil adopting a tautomer in which the N3 hydrogen is on O4. The IRMPD spectroscopic data are consistent with the computed infrared spectra for the lowest-energy structures in all cases.

Structures of [M(Ura-H)(H2 O)n ](+) (M = Mg, Ca, Sr, Ba; n = 1-3) complexes in the gas phase by IRMPD spectroscopy and theoretical studies.

The structures of singly and doubly (and for Mg, triply) hydrated group 2 metal dications bound to deprotonated uracil were explored in the gas phase using infrared multiple photon dissociation spectroscopy in the mid-infrared region (1000-1900 cm(-1) ) and the O-H/N-H stretching region (2700-3800 cm(-1) ) in a Fourier transform ion cyclotron resonance mass spectrometer. The infrared multiple photon dissociation spectra were then compared with the computed IR spectra for various isomers. Calculations were performed using B3LYP with the 6-31 + G(d,p) basis set for all atoms except Ba(2+) and Sr(2+) , for which the LANL2DZ or the def2-TZVPP basis sets with relativistic core potentials were used. Atoms-in-molecules analysis was conducted for all lowest energy structures. The lowest energy isomers in all cases are those in which the one uracil is deprotonated at the N3 position, and the metal is coordinated to the N3 and O4 of uracil. Regardless of the degree of solvation, all water molecules are bound to the metal ion and participate in a hydrogen bond with a carbonyl of the uracil moiety.