Assessing the Carbon Footprint of Telemedicine: A Systematic Review.

Background: Healthcare is responsible for 4% to 10% of carbon emissions worldwide, of which 22% is related to transport. Telemedicine emerged as a potential solution to reduce the footprint, for example, by reducing travel. However, a need to understand which variables to include in carbon footprint estimations in telemedicine limits our understanding of the beneficial impact telemedicine might have on our environment. This paper aims to systematically assess the reported carbon footprint and include variables assessed by the literature, comparing telemedicine with usual care. Methods: The systematic review followed the PRISMA guidelines in PubMed, Medline, Embase and Scopus. A quality assessment was performed using a transparency checklist for carbon footprint calculators. Carbon emissions were evaluated based on four categories, including patient travel, and streamlined life cycle assessment (LCA) for assessing included variables relevant to telemedicine. Results: We included 33 articles from 1117 records for analysis. The average transparency score was 38% (range 18%-68%). The median roundtrip travel distance for each patient was 131 km (interquartile range [IQR]: 60.8-351), or 25.6 kgCO2 (IQR: 10.6-105.6) emissions. There is high variance among included variables. Saved emissions are structurally underestimated by not including external factors such as a streamlined LCA. Conclusions: Telemedicine aids in reducing emissions, with travel distance being the most significant contributor. Additionally, we recommend accounting for the LCA since it highlights important nuances. This review furthers the debate on assessing carbon footprint savings due to telemedicine.

Pain mechanisms and management in corneal cross-linking: a review.

Though corneal collagen cross-linking (CXL) is an increasingly available and effective treatment for keratoconus, few reports have considered its impact on pain-related physiology in depth. This comprehensive narrative review summarises mechanisms underlying pain in CXL and clinical care possibilities, with the goal of future improvement in management of CXL-related pain. Postoperative pain associated with CXL is largely due to primary afferent nerve injury and, to a smaller extent, inflammation. Chronification of pain after CXL has not been reported, even as long-term nerve damage without regeneration following standard CXL treatment is frequently observed. The lack of pain chronification may be due to the minimally invasive nature of the procedure, with its rapidly recovering superficial corneal wound, and to the positive anti-inflammatory changes of the tear film that have been described after CXL. Different CXL approaches have been developed, with the transepithelial epithelial-on technique (epi-on) associated with less postsurgical pain than the gold standard, epithelial-off technique (epi-off). After the first few days, however, the difference in pain scores and need for analgesics between epi-on and epi-off disappear. Patients experience relatively high-intensity pain the first few days post-CXL, and many strategies for acute pain control following CXL have been studied. Currently, no method of pain management is considered superior or universally accepted. Acute pain following CXL is a recognised and clinically significant side effect, but few CXL studies have systematically investigated postoperative pain and its management. This review aims to improve patient pain outcomes following this increasingly common procedure.

Higher order optical aberrations and visual acuity in a randomized controlled trial comparing transepithelial versus epithelium-off corneal crosslinking for progressive keratoconus.

PURPOSE: The purpose of this study was to compare the effects of transepithelial crosslinking (trans-CXL) versus epithelium-off crosslinking (epi-off CXL) for progressive keratoconus with respect to the development of higher order aberrations (HOAs) and their effects on visual acuity. MATERIALS AND METHODS: A total of 61 patients were randomized and examined preoperatively and 1, 3, 6, and 12 months postoperatively in an academic referral center. Total corneal HOAs were compared between the two treatment groups using mixed linear modeling. Types of HOAs (coma, trefoil, and spherical aberration) that differed between groups were entered in a multivariable analysis to test their effect on uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA). RESULTS: The epi-off CXL group had more flattening in maximal keratometry compared to the trans-CXL group (P=0.02). UDVA did not differ significantly between the groups (P=0.59); however, CDVA was significantly more improved in the trans-CXL group (P=0.02). Horizontal trefoil improved more in the epi-off group compared to the trans-CXL group (P=0.04), whereas the other HOAs were virtually unchanged in both groups. Differences in changes in HOAs between the two groups had no effect on either UCVA (P=0.76) or CDVA (P=0.96). CONCLUSION: Although HOAs are clinically relevant determinants of vision quality in keratoconus patients, the change in total HOAs post treatment did not differ between the trans-CXL and epi-off CXL groups. Only horizontal trefoil differed significantly post treatment between the trans-CXL and epi-off CXL groups. However, this difference did not independently affect either UDVA or CDVA. Trans-CXL provides no benefit over epi-off CXL regarding visual relevant HOAs.

The Eyesi simulator in training ophthalmology residents: results of a pilot study on self-efficacy, motivation and performance.

Purpose: To describe ophthalmology residents' motivation and self-efficacy during cataract surgery training and to assess the relationship of self-efficacy and motivation on both simulator (Eyesi) and real-life surgical performance. Methods: Prospective cohort study using a within-subject design. Eight residents were asked to fill out questionnaires on self-efficacy and motivation towards the Eyesi simulator and real-life cataract surgery at three different moments. Simulator performance was derived from the instrument's output. Patient charts were reviewed to assess real-life surgical performance. Results: Comparative analysis, using a paired sampled t-test, showed a significant increase in self-efficacy towards real-life cataract surgery after completing the cataract training on the simulator (p=0.005). Furthermore, we found a significant correlation between total tasks to complete the cataract training and self-efficacy scored after working with the simulator (p=0.038). Motivation towards the simulator remained stable over time and seemed not to be influenced by simulator or real-life performance. Conclusions: We found evidence that performance on the simulator correlated with residents' self-efficacy scored after the simulator training, supporting the theory that self-efficacy is determined by prior performance. Self-efficacy seemed inversely related to the ease of completion of a task: delivery of a greater effort leads to more satisfaction and a higher perceived self-efficacy towards this particular task. Future studies should include more subjects to provide a more accurate insight in the role of self-efficacy and motivation in training complex surgical skills.

Comparison of Diaton transpalpebral tonometer with applanation tonometry in keratoconus.

AIM: To investigate the added value of using a Diaton transpalpebral tonometer (DT) to measure IOP in keratoconus. Most type of tonometers use corneal applanation or biomechanical resistance to measure intraocular pressure (IOP); however, these factors can be altered by keratoconus. Specifically, we examined whether DT can detect false-negative low Goldmann applanation tonometry (AT) measurements. METHODS: Patients with keratoconus were recruited from our tertiary academic treatment center. Measurements included AT and DT (in random order) and Scheimpflug imaging. An age- and gender-matched group of control subjects with no history of corneal disease or glaucoma was also recruited. RESULTS: In total, 130 eyes from 66 participants were assessed. In the keratoconus group, mean AT was 11.0 ± 2.6, mean DT 11.2±5.5 (P=0.729), and the two measures were correlated significantly (P=0.006, R=0.323). However, a Bland-Altman plot revealed a wide distribution and poor agreement between both measurements. Previous corneal crosslinking, corneal pachymetry, and Krumeich classification had no effect on measured IOP. CONCLUSION: Measurements obtained using a Diaton tonometer are not affected by corneal biomechanics; however, its poor agreement with Goldmann AT values calls into question the added value of using a Diaton tonometer to measure IOP in keratoconus.