Clinical indicators for diabetic eyecare delivered by optometrists in Australia: a Delphi study.

CLINICAL RELEVANCE: Valid and updated clinical indicators can serve as important tools in assessing and improving eyecare delivery. BACKGROUND: Indicators for diabetic eyecare in Australia were previously developed from guidelines published before 2013 and then used to assess the appropriateness of care delivery through a nationwide patient record card audit (the iCareTrack study). To reflect emerging evidence and contemporary practice, this study aimed to update clinical indicators for optometric care for people with type 2 diabetes in Australia. METHODS: Forty-five candidate indicators, including existing iCareTrack and new indicators derived from nine high-quality evidence-based guidelines, were generated. A two-round modified Delphi process where expert panel members rated the impact, acceptability, and feasibility of the indicators on a 9-point scale and voted for inclusion or exclusion of the candidate indicators was used. Consensus on inclusion was reached when the median scores for impact, acceptability, and feasibility were ≥7 and >75% of experts voted for inclusion. RESULTS: Thirty-two clinical indicators with high acceptability, impact and feasibility ratings (all median scores: 9) were developed. The final indicators were related to history taking (n = 12), physical examination (n = 8), recall period (n = 5), referral (n = 5), and patient education/communication (n = 2). Most (14 of 15) iCareTrack indicators were retained either in the original format or with modifications. New indicators included documenting the type of diabetes, serum lipid level, pregnancy, systemic medications, nephropathy, Indigenous status, general practitioner details, pupil examination, intraocular pressure, optical coherence tomography, diabetic retinopathy grading, recall period for high-risk diabetic patients without retinopathy, referral of high-risk proliferative retinopathy, communication with the general practitioner, and patient education. CONCLUSION: A set of 32 updated diabetic eyecare clinical indicators was developed based on contemporary evidence and expert consensus. These updated indicators inform the development of programs to assess and enhance the eyecare delivery for people with diabetes in Australia.

A clinical method for estimating the modulus of elasticity of the human cornea in vivo.

BACKGROUND: To develop a method, using current clinical instrumentation, to estimate the Young's modulus of the human cornea in vivo. METHODS: Central corneal curvature (CCC), central corneal thickness(CCT), intraocular pressure (IOP) was measured with the Goldmann tonometer (IOPG) and the Pascal Dynamic Corneal Tonometer(PDCT) in one eye of 100 normal young human subjects (21.07 ± 2.94 years) in vivo. The Orssengo and Pye algorithm was used to calculate the Young's modulus of the corneas of these subjects. RESULTS: The Young's modulus(E) of the corneas of the subjects using the PDCT and IOPG results (Ecalc) was 0.25 ± 0.10MPa, and without the PDCT results (Eiopg) was 0.29 ± 0.06MPa. The difference in these results is due to the difference in tonometry results between the two instruments, as the mean PDCT result for the subjects was 16.89 ± 2.49mmHg and the IOPG result 15.06 ± 2.71mmHg. E was affected by the CCC of the subjects but more particularly by the CCT and IOP measurements. Corneal stiffness results are also presented. CONCLUSION: Two methods have been developed to estimate the Young's modulus of the human cornea in vivo using current clinical instrumentation. One method (Ecalc) is applicable to the general corneal condition, and Eiopg to the normal cornea, and these results can be used to calculate corneal stiffness.

Preliminary identification of differentially expressed tear proteins in keratoconus.

PURPOSE: To examine the proteins differentially expressed in the tear film of people with keratoconus and normal subjects. METHODS: Unstimulated tears from people with keratoconus (KC) and controls (C) were collected using a capillary tube. Tear proteins from people with KC and controls were partitioned using a novel in-solution electrophoresis, Microflow 10 (ProteomeSep), and analyzed using linear ion trap quadrupole fourier transform mass spectrometry. Spectral counting was used to quantify the individual tear proteins. RESULTS: Elevated levels of cathepsin B (threefold) were evident in the tears of people with KC. Polymeric immunoglobulin receptor (ninefold), fibrinogen alpha chain (eightfold), cystatin S (twofold), and cystatin SN (twofold) were reduced in tears from people with KC. Keratin type-1 cytoskeletal-14 and keratin type-2 cytoskeletal-5 were present only in the tears of people with KC. CONCLUSIONS: The protein changes in tears, that is, the decrease in protease inhibitors and increase in proteases, found in the present and other previously published studies reflect the pathological events involved in KC corneas. Further investigations into tear proteins may help elucidate the underlying molecular mechanisms of KC, which could result in better treatment options.

Effects of eye rubbing on the levels of protease, protease activity and cytokines in tears: relevance in keratoconus.

BACKGROUND: Proteases, protease activity and inflammatory molecules in tears have been found to be relevant in the pathogenesis of keratoconus. We sought to determine the influence of eye rubbing on protease expression, protease activity and concentration of inflammatory molecules in tears. METHODS: Basal tears were collected from normal volunteers before and after 60 seconds of experimental eye rubbing. The total amount of matrix metalloproteinase (MMP)-13 and inflammatory molecules interleukin (IL)-6 and tumour necrosis factor (TNF)-α in the tear samples were measured using specific enzyme-linked immunosorbent assays (ELISA). Tear collagenase activity was investigated using a specific activity assay. RESULTS: The concentrations of MMP-13 (51.9 ± 34.3 versus 63 ± 36.8 pg/ml, p = 0.006), IL-6 (1.24 ± 0.98 versus 2.02 ± 1.52 pg/ml, p = 0.004) and TNF-α (1.16 ± 0.74 versus 1.44 ± 0.66 pg/ml, p = 0.003) were significantly increased in normal subjects after eye rubbing. The experimental eye rub did not alter significantly the collagenase activity (5.02 ± 3 versus 7.50 ± 3.90 fluorescent intensity units, p = 0.14) of tears. CONCLUSION: Eye rubbing for 60 seconds increased the level of tear MMP-13, IL-6 and TNF-α in normal study subjects. This increase in protease, protease activity and inflammatory mediators in tears after eye rubbing may be exacerbated even further during persistent and forceful eye rubbing seen in people with keratoconus and this in turn may contribute to the progression of the disease.

Associations between diurnal changes in Goldmann tonometry, corneal geometry, and ocular response analyzer parameters.

PURPOSE: To investigate the possible covariations between diurnal changes in Goldmann applanation tonometry (GAT) estimates of intraocular pressure (IOP), central corneal thickness (CCT), central corneal radius, and ocular response analyzer measures of corneal hysteresis and corneal resistance factor (CRF). METHODS: Twenty-five healthy normal subjects (age, 21 ± 2 years) had central corneal radius, ocular response analyzer, GAT, and CCT measurements performed in 1 eye at multiple times for more than 24 hours. Measurements were taken at 17:00 and repeated every 2 hours until 23:00. Subjects then slept uninterrupted overnight for approximately 8 hours. On awakening, readings were taken at a 20-minute frequency from 7:00 to 9:00 inclusive, followed by 2 hourly intervals until 17:00. RESULTS: The maximum variation in GAT for more than 24 hours was 2.5 mm Hg, and these fluctuations were predicted by the diurnal variations of CCT (0.37 mm Hg ΔGAT/10 µm CCT, P < 0.01) and CRF (0.68 mm Hg ΔGAT/mm Hg CRF, P < 0.01). The diurnal changes in corneal hysteresis and CRF both covaried with those of CCT (0.16 and 0.30 mm Hg/10 µm ΔCCT, respectively, both Ps < 0.01). None of these associations was statistically different during and after the nominal period of resolution from overnight corneal swelling (2-way interactions, all Ps > 0.05). CONCLUSIONS: If the IOP is assumed to be independent of corneal parameters, the clinically significant 24-hour variation in GAT being partially predicted by the changes in CCT and CRF suggests that the diurnal variation in corneal parameters affects tonometry measurements. CRF may also be dependent on the level of IOP.

Are proteinases the reason for keratoconus?

PURPOSE: Keratoconus is a degenerating disease of the eye that results in an irregularly-shaped cornea. The etiology of the disease is unknown and the prognosis is difficult due to the variability in outcome. Keratoconus has been associated with eye rubbing, atopy, contact lens wear, as well as genetic conditions, such as Down's syndrome, Ehlers-Danlos syndrome, and Marfan's syndrome. Thinning of the cornea in keratoconus has been well studied and is documented to occur as a result of degradation of corneal collagen. The reason for this tissue degradation is unknown but has been hypothesized to be linked with proteases. METHODS: This study used a literature search to review the role of proteases and inflammatory molecules in the aetiology of keratoconus. RESULTS: Early studies demonstrated elevated levels of collagenolytic and gelatinolytic activities in laboratory cultures of keratoconic corneas. Matrix metalloproteinases (MMPs) are a family of zinc-dependent proteins that include collagenases and gelatinases. MMPs levels are altered in keratoconus corneas compared to normal corneas and the level of tissue inhibitor of metalloproteinases-1 (TIMP-1) is decreased in keratoconic corneas. Recent studies have demonstrated the involvement of Cathepsin B, G, and K in keratoconus. Although thought to be a non-inflammatory disease, inflammatory molecules, such as interleukins and tumor necrosis factor have been shown to be elevated in keratoconus, and these inflammatory molecules may mediate production and activation of proteases. CONCLUSIONS: Proteases may be implicated in keratoconus. An in-depth investigation of these proteases may help in better understanding the course of the disease.

Young's modulus in normal corneas and the effect on applanation tonometry.

OBJECTIVES: To determine the statistically normal range of corneal Young's modulus in young healthy eyes in vivo, and to establish if this variation has a clinically significant influence on intraocular pressure (IOP) measurement using applanation tonometry. METHODS: Central corneal curvature, central corneal thickness (CCT), and applanation IOP (Goldmann tonometer) were measured using standard clinical techniques in one eye of 100 normal human subjects (22.0 +/- 2.9 years) in vivo. The Orssengo-Pye algorithm was used to calculate the corneal Young's modulus of these experimental subjects, and to produce a theoretical model of potential errors in Goldmann applanation tonometry estimates of IOP due to variations of Young's modulus and CCT. RESULTS: Corneal Young's modulus was 0.29 +/- 0.06 MPa [95% confidence interval (CI) 0.17 to 0.40 MPa]. According to the Orssengo-Pye model, the relationship between Young's modulus and the error in applanation IOP is linear; the slope was 23 mm Hg per MPa. An increase from the minimum to the maximum value of the calculated limits of agreement (95% CI) of Young's modulus caused a variation in applanation IOP of 5.35 mm Hg. The anticipated error at the extremes of the limits of agreement (95% CI) of CCT was similar at 4.67 mm Hg. CONCLUSION: Physiological variations in corneal Young's modulus may cause clinically significant errors in Goldmann applanation tonometry estimates of IOP.

The effect of corneal edema on dynamic contour and goldmann tonometry.

PURPOSE: To determine the effect of contact lens-induced corneal edema on measurements of intraocular pressure (IOP) using the Pascal dynamic contour tonometer (DCT), compared with the Goldmann tonometer. METHODS: Thirty young healthy subjects (23.0 +/- 3.0 years) were recruited from the student population at the University of New South Wales. Thick hydroxyethyl methacrylate contact lenses were worn monocularly for 2 hours under closed-eye conditions to induce corneal edema via hypoxia. IOP (Goldmann and Pascal DCT), ocular pulse amplitude (OPA), and central corneal thickness (CCT) were measured in both eyes before and after lens wear. Paired t-tests, Pearson correlation, and Bland-Altman plots were used to identify changes in, and relationships between, these parameters resulting from corneal edema. RESULTS: Lens wear resulted in statistically significant changes in CCT (+48.3 +/- 14.4 microm, p < 0.001), Goldmann IOP (+1.5 +/- 2.8 mm Hg, p = 0.007), and Pascal DCT IOP (-0.7 +/- 1.1 mm Hg, p = 0.001) but not OPA (0.0 +/- 0.3 mm Hg, p = 0.721, two-tailed paired t-test). The Pascal DCT provided IOP readings that were 1.3 +/- 2.0 mm Hg higher than the Goldmann IOP readings when hydration was normal, but the Goldmann tonometer provided readings that were 0.8 +/- 2.5 mm Hg higher than the Pascal DCT readings when the cornea was edematous. The variation between the two instruments was weakly correlated to the change in CCT (r = -0.261, p = 0.044). CONCLUSIONS: Contact lens-induced corneal edema caused a small underestimation error in IOP measurements by the Pascal DCT, and an overestimation error in Goldmann tonometry measurements. The OPA measurement provided by the Pascal DCT is insensitive to corneal edema-induced changes in corneal properties.

The effect of contact lens induced corneal edema on Goldmann applanation tonometry measurements.

AIM: To determine the effect of small increases in corneal hydration on the accuracy of Goldmann applanation tonometry estimates of intraocular pressure (IOP). MATERIALS AND METHODS: Twenty-five young healthy subjects presented on 3 separate days approximately 1 week apart. On 2 visits, subjects were required to wear a hydrogel contact lens with either a center thickness of 0.3 and 0.7 mm (HEMA 38% water content, parallel surface curve) in 1 eye only under closed-eye conditions for 2 hours to induce corneal swelling. The third visit acted as a control. IOP, corneal thickness, and corneal curvature were measured in both eyes before and after contact lens wear on all visits. RESULTS: There was a statistically significant increase in corneal thickness of 40.2+/-14.4 microm (P<0.001) and 41.9+/-16.4 microm (P<0.001) after wearing the 0.3 and 0.7 mm thick contact lenses, respectively (2-tailed paired t test). There was an increase in IOP of 2.8+/-2.2 mm Hg (P<0.001) after wearing the 0.3 mm thick contact lens, and a statistically insignificant difference of 1.3+/-3.0 mm Hg (P=0.058) after wearing the 0.7 mm thick contact lens (2-tailed paired t test). There was a statistically significant Pearson correlation between the change in corneal thickness and the change in IOP after lens wear (r=0.500, P<0.001, 0.3 mm lens and r=0.399, P<0.001, 0.7 mm lens). The corneal hydration-induced measurement error was 0.46 mm Hg per 10 microm change in corneal thickness (0.3 mm lens) and 0.35 mm Hg per 10 microm change in corneal thickness (0.7 mm lens). CONCLUSION: A small increase in corneal hydration and thickness may cause a clinically significant overestimation of IOP when measured using Goldmann applanation tonometry.