Assessing low vision care and the utilisation of optical low vision aids among patients with visual impairment in Taiwan.

PURPOSE: The aim of this study was to examine the quality of assessment and the utilisation of optical low vision aids (OLVAs) among people with visual impairment (VI) in Taiwan. METHODS: The study included 577 participants between 4 and 100 years of age (314 males and 263 females). All participants had been certified by the Ministry of the Interior of Taiwan, indicating that they had undergone a thorough and comprehensive low vision assessment, including evaluation of visual acuity (VA), contrast sensitivity, colour vision, visual fields and glare disability. Furthermore, all participants who consented to refraction had received prescriptions for OLVAs. RESULT: All participants were prescribed one or more OLVAs such as eyeglasses, tinted lenses, magnifiers, closed-circuit television magnifiers, telescopes, or screen magnifiers. Among the 577 individuals, 515 received correction for refractive errors, providing the best-corrected VA (BCVA). The improvement in VA was significant at both distance and near, improving from 1.29 ± 0.55 to 1.01 ± 0.52 logMAR (p < 0.001) and from 1.29 ± 0.56 to 1.01 ± 0.52 logMAR (p < 0.001), respectively. Eyeglasses were the primary OLVAs chosen by 333 participants (64.7%), while 53.3%-80.3% of participants combined eyeglasses with other OLVAs to enhance their visual performance. CONCLUSIONS: The most commonly used and effective OLVA was eyeglasses. Skilfully utilising appropriate refractive and VA measurements is crucial for determining the most suitable and beneficial OLVA for individuals with VI.

Analyzing the effectiveness of teaching and factors in clinical decision-making.

OBJECTIVE: The aim of this study is to prepare junior physicians, clinical education should focus on the teaching of clinical decision-making. This research is designed to explore teaching of clinical decision-making and to analyze the benefits of an "Analogy guide clinical decision-making" as a learning intervention for junior doctors. MATERIALS AND METHODS: This study had a "quasi-experimental design" and was conducted in a medical center in eastern Taiwan. Participants and Program Description: Thirty junior doctors and three clinical teachers were involved in the study. The experimental group (15) received 1 h of instruction from the "Analogy guide for teaching clinical decision-making" every day for 3 months. Program Evaluation: A "Clinical decision-making self-evaluation form" was used as the assessment tool to evaluate participant learning efficiency before and after the teaching program. Semi-structured qualitative research interviews were also conducted. RESULTS: We found using the analogy guide for teaching clinical decision-making could help enhance junior doctors' self-confidence. Important factors influencing clinical decision-making included workload, decision-making, and past experience. CONCLUSION: Clinical teaching using the analogy guide for clinical decision-making may be a helpful tool for training and can contribute to a more comprehensive understanding of decision-making.

Ophthalmologic abnormalities among students with cognitive impairment in eastern Taiwan: The special group with undetected visual impairment.

PURPOSE: Students with cognitive impairment are at increased risk of suffering from visual impairment due to refractive errors and ocular disease, which can adversely influence learning and daily activities. The purpose of this study was to evaluate the ocular and visual status among students at the special education school in Hualien. METHODS: All students at the National Hualien Special Education School were evaluated. Full eye examinations were conducted by a skilled ophthalmologist. The students' medical records and disability types were reviewed. RESULTS: A total of 241 students, aged 7-18 years, were examined. Visual acuity could be assessed in 138 students. A total of 169/477 (35.4%) eyes were found to suffer from refractive errors, including 20 eyes with high myopia (≤-6.0 D) and 16 eyes with moderate hypermetropia (+3.0 D to +5.0 D). A total of 84/241 (34.8%) students needed spectacles to correct their vision, thus improving their daily activities and learning process, but only 15/241 (6.2%) students were wearing suitable corrective spectacles. A total of 55/241 students (22.8%) had ocular disorders, which influenced their visual function. The multiple disability group had a statistically significant higher prevalence of ocular disorders (32.9%) than the simple intellectual disability group (19.6%). CONCLUSION: Students with cognitive impairment in eastern Taiwan have a high risk of visual impairment due to refractive errors and ocular disorders. Importantly, many students have unrecognized correctable refractive errors. Regular ophthalmic examination should be administered to address this issue and prevent further disability in this already handicapped group.

The prevalence and risk factors of visual impairment among the elderly in Eastern Taiwan.

Visual impairment is associated with disability and poor quality of life. This study aimed to investigate the prevalence and associated risk factors of visual impairment among the suburban elderly in Eastern Taiwan. The cross-sectional research was conducted from April 2012 to August 2012. The ocular condition examination took place in suburban areas of Hualien County. Medical records from local infirmaries and questionnaires were utilized to collect demographic data and systemic disease status. Logistic regression models were used for the simultaneous analysis of the association between the prevalence of visual impairment and risk factors. Six hundred and eighty-one residents participated in this project. The mean age of the participants was 71.4±7.3 years. The prevalence of vision impairment (better eye<6/18) was 11.0%. Refractive error and cataract were the main causes of vision impairment. Logistic regression analysis showed that people aged 65-75 years had a 3.8 times higher risk of developing visual impairment (p=0.021), while the odds ratio of people aged > 75 years was 10.0 (p<0.001). In addition, patients with diabetic retinopathy had a 3.7 times higher risk of developing visual impairment (p=0.002), while the odds ratio of refractive error was 0.36 (p<0.001). The prevalence of visual impairment was relatively high compared with previous studies. Diabetic retinopathy was an important risk factor of visual impairment; by contrast, refractive error was beneficial to resist visual impairment. Therefore, regular screening of ocular condition and early intervention might aid in the prevention of avoidable vision loss.

Eye care services for the populations of remote districts in eastern Taiwan: a practical framework using a Mobile Vision Van Unit.

INTRODUCTION: To put a blindness prevention program into practice in remote districts of Eastern Taiwan, a Mobile Vision Van Unit (MVVU) was established to work as a community eyecare station. The aim of this study was to describe the operation and challenges encountered with this unit and its efficacy in expanding eyecare services. METHODS: A population-based primary eyecare model was applied to a population in remote regions of eastern Taiwan. An MVVU, equipped with an autorefractometer, a non-contact tonometer, a slit-lamp biomicroscope, a retinoscope, an ophthalmoscope and a mini optician workshop was taken into remote areas of eastern Taiwan to provide comprehensive eyecare services. An integrated vertical referral system for further diagnosis and treatment was also employed. Data including the services provided, spectacles dispensed, health promotion activities conducted and the effectiveness of the model were collected and analysed. The main outcome measures were practicability of a primary eyecare model, prevalence of visual impairment and the major causes in middle-aged and elderly patients. RESULTS: Between 2002 and 2008, a total of 600 primary eyecare services were delivered to 28 indigenous villages and remote townships in eastern Taiwan. The MVVU screened a total of 35 275 inhabitants. The ages of those screened ranged from preschool children to the elderly, and 2073 patients were referred to secondary or tertiary centres in the middle-aged and elderly blindness prevention program. On-site dispensing of low-cost spectacles and the rapid delivery of more complex prescriptions were provided without charge to 1816 participants who could not afford glasses. In addition, 118 eye health educational programs and training courses for paramedical personnel and volunteers were conducted. CONCLUSIONS: An MVVU model for blindness prevention is highly feasible in its efficiency and cost-effectiveness in communities with deficient medical resources.

Human adenovirus type 8 epidemic keratoconjunctivitis with large corneal epithelial full-layer detachment: an endemic outbreak with uncommon manifestations.

Epidemic viral conjunctivitis is a highly contagious disease that is encountered year-round. The causative agents are mainly adenoviruses and enteroviruses. It occurs most commonly upon infection with subgroup D adenoviruses of types 8, 19, or 37. For common corneal involvement of human adenovirus type 8 epidemic keratoconjunctivitis, full-layer epithelial detachment is rarely seen. Herein, we report three cases of epidemic keratoconjunctivitis during an outbreak which manifested as large corneal epithelial full-layer detachment within a few days. The lesions healed without severe sequelae under proper treatment. The unique manifestation of this outbreak may indicate the evolution of human adenovirus type 8.

A novel gene mutation in a family with X-linked retinoschisis.

BACKGROUND/PURPOSE: To describe the clinical characteristics of a Taiwanese family with X-linked retinoschisis (XLRS) and to investigate the molecular genetics of a novel mutation in the retinoschisin 1 (RS1) gene. METHODS: A total of 15 participants in this XLRS family were analyzed. Complete ophthalmic examinations and fundus photography were performed on 15 family members. These tests identified five affected males and two female carriers. Blood samples were collected, and genomic DNA was extracted. Best-corrected visual acuity, optical coherence tomography (OCT), electroretinogram (ERG), and direct DNA sequence analysis of the RS1 gene were performed on 15 family members. RESULTS: Five affected males, with visual acuity ranging from 0.2 to 0.7, had macular schisis and abnormal retinal pigment epithelium pigmentation. The mixed scotopic ERG "b" wave was more reduced than the "a" wave. OCT revealed typical microcystic schisis cavities within the macula area. Direct DNA sequence analysis revealed a single base pair deletion, 97delT, in all the affected individuals. This deletion resulted in a frameshift mutation of the RS1 gene, causing protein truncation. The affected males in this family showed moderately decreased visual acuity and dysfunction in both cone cells and phototransduction. CONCLUSION: We identified a novel RS1 (97delT) mutation in a Taiwanese family with XLRS. This finding expands the RS1 mutation spectrum and may help to further understand the molecular pathogenesis of XLRS.

Basaloid squamous cell carcinoma of the conjunctiva.

Basaloid squamous cell carcinoma is a distinct variant of squamous cell carcinoma, and it is more aggressive and has a poorer prognosis than conventional squamous cell carcinoma. Basaloid squamous cell carcinoma has been reported to arise from many organs, mainly in the upper aerodigestive tract. Herein, the authors present a 77-year-old woman with a basaloid squamous cell carcinoma over her limbal conjunctiva in the OD.

Protective effects of cerebrolysin in a rat model of optic nerve crush.

To investigate the effects of cerebrolysin (Cbl) on optic nerves (ON) and retinal ganglion cells (RGC) in a rat model of ON crush. Rats received intravitreal injection of Cbl (n = 20), intra-ON injection of Cbl (n = 20), intraperitoneal injection (IPI) of Cbl (n = 20), or phosphate buffered saline (PBS; n = 20) every day for 2 weeks after ON crush injury. At 3 weeks post-trauma, RGC density was counted by retrograde labeling with FluoroGold and visual function was assessed by flash visual-evoked potentials. Activities of microglia after insults were quantified by immunohistochemical analysis of the presence of ED1 in the optic nerve. At 3 weeks postcrush, the densities of RGCs in the Cbl-IVI group (1125 ± 166/mm(2)) and in the Cbl-IPI treatment group (1328 ± 119/mm(2)) were significantly higher than those in the PBS group (641 ± 214/mm(2)). The flash visual-evoked potential measurements showed that latency of the P1 wave was significantly shorter in the Cbl-IVI- and Cbl-IPI-treated groups (105 ± 4 ms and 118 ± 26 ms, respectively) than in the PBS-treated group (170 ± 20 ms). However, only Cbl IPI treatment resulted in a significant decrease in the number of ED1-positive cells at the lesion sites of the ON (5 ± 2 cells/vs. 30 ± 4 cells/high-power field in control eyes). Treatment with intra-ON injection of Cbl was harmful to the optic nerve in the crush model. Systemic administration of Cbl had neuroprotective effects on RGC survival and visual function in the optic nerve crush model.

Factors influencing the retrograde labeling of retinal ganglion cells with fluorogold in an animal optic nerve crush model.

PURPOSE: To investigate whether different crush durations or a different fluorogold (FG) injection timing can affect the efficiency of FG retrograde labeling of retinal ganglion cells (RGCs) in the optic nerve (ON) crush model. METHODS: We performed the ON crush in rats with a clip at different durations or a jewel forceps to compare the effects of different crush methods with FG staining. RGC density was compared between the FG injection 1 week before the sacrifice of the animals (group A) and the injection before the crush experiment (group B). Double staining with CD11b and FG in the retinal sections was conducted to investigate the relationship between the overcounting of RGCs and microglia. RESULTS: The FG-stained particles were significantly decreased at the distal part of the crush site compared to the proximal site of the ON with a crush duration of over 30 s or when crushed with the jewel forceps. Two weeks after ON crush, the RGC count was higher both in the central and mid-peripheral retinas in group B. The percentage of CD11b-stained cells among the FG-stained cells in the RGC layer of retinas in group B was higher than that of group A (34% in group B vs. 4% in group A, p = 0.0001). Overcounting of RGC density in group B was due to additional microglia with FG engulfing. CONCLUSIONS: Our results suggest that each laboratory should test its setting conditions to avoid factors influencing the RGC density measurement before conducting ON crush experiments.

Prevalence and causes of visual impairment in elderly Amis aborigines in Eastern Taiwan (the Amis Eye Study).

PURPOSE: To investigate the prevalence and causes of visual impairment in elderly Amis aborigines in Eastern Taiwan. METHODS: Population-based cross-sectional study of visual impairment of elderly Amis (65 years of age or older). We conducted ocular examinations on 2,316 participants, which represent 61.2 % of the elderly population. We used WHO criteria to identify visual impaired subjects, and the causes were analyzed. RESULTS: Ninety-four subjects were identified with low vision and nineteen were blind. The prevalence of low vision was 4.06 % (95 % confidence interval, 3.26, 4.56 %); that of blindness was 0.82 % (95 % confidence interval, 0.45, 1.19 %). Cataracts (47.79 %) were the main cause of visual impairment, followed by age-related macular degeneration (15.93 %), corneal opacity (7.96 %), optic neuropathy (7.96 %), diabetic retinopathy (5.31 %), and retinitis pigmentosa (2.65 %). Glaucoma was a minor cause of visual impairment. There were no significant gender differences in the prevalence and specific causes of visual impairment. CONCLUSION: The prevalence of treatable causes of vision impairment, for example cataracts and corneal opacity, is high among the elderly Amis aborigines. They would, therefore, benefit from a more aggressive and in-depth eye-care program as a blindness-prevention strategy.

Effects of age and disc area on optical coherence tomography measurements and analysis of correlations between optic nerve head and retinal nerve fibre layer.

BACKGROUND: The aim here was to investigate whether optic nerve head (ONH) parameters or retinal nerve fibre layer (RNFL) thickness correlate with age or disc area and whether the neuroretinal rim correlates with RNFL thickness. METHODS: This cross-sectional study enrolled 133 healthy subjects and analysed one randomly selected eye of each subject. All measurements of ONH parameters (including neuroretinal rim, disc and cup areas and cup-to-disc ratios) and RNFL thickness (global and quadrants) were taken by a single experienced operator using optical coherence tomography (OCT). RESULTS: Of the rim parameters analysed, average nerve width (the height of the nerve fibre bundle) was independent of age or disc area (p > 0.05). Disc area correlated positively with cup area (p < 0.05) but not with cup-to-disc ratios (p > 0.05). Of the RNFL thickness measurements analysed, temporal RNFL was independent of both age and disc area (p > 0.05). According to the analysis of the correlation between RNFL thickness and neuroretinal rim, global or non-temporal RNFL correlated positively with horizontal integrated rim width (p < 0.05, F > 4.000) and temporal RNFL was independent of all rim parameters (p > 0.05, F < 4.000). CONCLUSION: Aging effect on neuroretinal rim loss or RNFL thickness change is non-uniform, and age is not a constant confounder when using OCT. The temporal RNFL is independent of age, disc area and neuroretinal rim.

Lack of protective effect of local administration of triamcinolone or systemic treatment with methylprednisolone against damages caused by optic nerve crush in rats.

The purpose of the present study was to investigate the effects of administrations of triamcinolone acetonide and systemic methylprednisolone sodium succinate on optic nerves (ON) and retinal ganglion cells (RGC) in a rat model of optic nerve crush. The treated groups either received triamcinolone immediately in the form of two pieces of soaked-gelform surrounding retrobulbar optic nerves (0.5 mg/per gelform) or methylprednisolone via peritoneal injection, and control group received intra-peritoneal injection with phosphate-buffered saline (PBS) after crush experiments. RGC density was counted by retrograde labeling with Fluorogold, and visual function was assessed by flash visual-evoked potentials. Terminal transferase dUTP nick end-labeling (TUNEL) assays, Western blot analysis of serine/threonine kinase (p-Akt), extracellular signal-regulated kinases (p-ERK) and signal transducer and activator of transcription 3 (p-STAT3) and immunohistochemistry of ED1, marker of macrophage/microglia in the optic nerve were conducted. Two and four weeks after optic nerve crush experiments, neither triamcinolone nor methylprednisolone treatment rescued the RGC from death in the central and mid-peripheral retinas compared with those of the corresponding optic nerve-crushed and PBS-treated rats. Visual-evoked potentials measurements showed a prolonged latency of the P(1) wave in all treated groups (triamcinolone-treated: 123 ± 23 ms, methylprednisolone-treated: 133 ± 25 ms and PBS-treated: 151 ± 55 ms) after two weeks. TUNEL assays showed that there was no decrease in apoptotic cells in the RGC layers of both triamcinolone treated and methylprednisolone-treated retinas. Western blot analysis showed that p-AKT, p-ERK and p-Stat3 were not up-regulated in either retina of the triamcinolone or methylprednisolone treated rats. In addition, the number of ED1-positive cells was not attenuated at the lesion sites of the ON in either treatment group. Based upon these results, we conclude that neither retrobulbar administration of triamcinolone nor systemic administration of methylprednisolone has any neuroprotective effects in a rat model of optic nerve crush.

Etiology of ocular diseases in elderly Amis aborigines in Eastern Taiwan (The Amis Eye Study).

PURPOSE: To determine the incidence of and risk factors associated with major ocular diseases in the elderly Amis population of Taiwan. METHODS: This population-based cross-sectional study is the most current survey of ocular diseases among elderly Amis. The overall response rate was 61.2%, with 2316 participants screened. All ocular examinations were performed using a mobile ophthalmology setup staffed by an ophthalmologist with 30 years of experience. RESULTS: The mean age of the participants was 71.65 years. Cataracts were the most common ocular disease (82.6%), followed by pterygium (44.1%), arteriosclerotic changes in retinal vessels (35.7%), hypertensive retinopathy (18.5 %), age-related macular degeneration (5.2%), optic neuropathy (4.6%), corneal opacity (4.6%), and diabetic retinopathy (3.3%). Glaucoma (1.0%) and high myopia (0.39%) were minor ocular diseases among elderly Amis. The prevalence of diabetes was 15.4% and that of hypertension was 40.0%. CONCLUSIONS: Treatable diseases such as cataracts and pterygium were the most common ocular diseases in the Amis tribes. The relatively low incidence of glaucoma was likely due to the unique genetic background of this population.

Optical coherence tomography of a coexisting optic nerve cyst and optic disc pit: a case report.

We describe a rare case of an optic pit located over the nasal portion of the disc that was independent of a coexisting optic nerve cyst. A healthy 35-year-old patient was referred to our clinic seeking alternative treatment options because his previous ophthalmologist had suggested evisceration and orbital surgery for a suspected orbital malignancy. Our examinations revealed a gray lesion located within the right disc cup that was associated with a round lesion at the retrobulbar optic nerve. Based on optical coherence tomography and magnetic resonance imaging findings, we believe that our patient exhibited an optic disc pit coexisting with a congenital optic nerve cyst. Because the patient had very good central vision and the lesions were benign, we recommended continued observation for this patient.

Anti-apoptotic effects of human granulocyte colony-stimulating factor (G-CSF) on retinal ganglion cells after optic nerve crush are PI3K/AKT-dependent.

The purpose of present study is to dissect the role of PI3K/AKT signaling in the anti-apoptotic effects of human granulocyte colony-stimulating factor (G-CSF) on rat retinal ganglion cells (RGCs) after optic nerve (ON) crush. The ONs of seventy-two adult male Wistar rats were crushed by a standardized method. Control eyes received a sham operation. G-CSF or phosphate-buffered saline (PBS) was immediately administrated after the ON event for 5 days. Twelve rats were used to investigate the signaling pathways using western blot analysis. In other sixty rats, each eye also received intravitreal injections of PI3K/AKT inhibitor (LY294002) or PBS immediately after the experiments. Rats were euthanized at 1 or 2 weeks after the experiment. RGC density was counted by retrograde labeling with Fluorogold. Western blot analysis of p-AKT, TUNEL assays, and immunohistochemistry of the retinas were conducted. Two weeks after ON injury, RGC densities in the central and mid-peripheral retinas of ON-crushed, G-CSF treated rats were significantly higher than those of corresponding ON-crushed, G-CSF-treated and LY294002-injected rats (survival rates of 60% vs. 39% and 43% vs. 33%, respectively; p < 0.01). Decreased TUNEL staining and the up-regulations of p-AKT signaling in retinas of ON-crushed, G-CSF-treated rats were blocked by intravitreal injections of LY294002. The double staining showed that p-AKT expression co-localized with RGCs in the ON crushed, G-CSF treated retinas. In conclusion, the anti-apoptotic effects of G-CSF on RGCs are PI3K/AKT signaling dependent in the retinas to rescue RGCs after ON crush injury.

Acute vision loss after intravitreal injection of bevacizumab (avastin) associated with ocular ischemic syndrome.

AIM: To report a patient with diabetic rubeosis who suffered from acute retinal ischemic change and stroke after intravitreal injection of bevacizumab. METHODS: A 55-year-old man had diabetes with unilateral rubeosis and macular edema. Three days after receiving intravitreal injection of bevacizumab (1.25 mg in 0.1 ml), he developed acute vision loss and change of consciousness. A complete ocular examination, fluorescein angiography, carotid artery Doppler sonography and brain magnetic resonance imaging were performed. RESULTS: Best corrected visual acuity before injection was 6/60 in the left eye. He had underlying left carotid artery stenosis combined with bilateral preproliferative diabetic retinopathy. Three days after intravitreal injection of bevacizumab, acute ocular ischemic syndrome occurred. He also suffered from acute stroke, and brain magnetic resonance angiography showed total left internal carotid artery occlusion. The final visual acuity was no light perception in the left eye and 3/6 in the right eye. CONCLUSIONS: Patients receiving intravitreal injections of bevacizumab should be evaluated for potential systemic risk factors such as carotid insufficiency, coagulopathy and poorly controlled diabetes mellitus. Acute ocular ischemic change may be associated with intravitreal injection of bevacizumab in patients with vascular compromised diabetic retinopathy and/or underlying stenosis of the carotid artery.

Homonymous hemianopia caused by solitary skull metastasis of hepatocellular carcinoma.

We report a patient who developed a complete left homonymous hemianopia from mass effect of a solitary skull metastasis of hepatocellular carcinoma (HCC). After chemoembolization and resection, the visual field defect improved markedly. This is the first reported case demonstrating this phenomenon in HCC. It supports aggressive treatment of a solitary skull metastasis in this setting.