Testing a Popular Smartphone Application for Colour Vision Assessment in Healthy Volunteer Subjects.

We aimed to compare the Ishihara pseudoisochromatic colour vision test with a colour vision test from a popular smartphone application (EyeHandBook [EHB]) using digital image processing to simulate colour vision deficiencies. Three digital versions of the Ishihara and EHB slides were created: full colour; 32 bit- greyscale (removing all colour information); and blue channel (to simulate red-green colour vision deficiencies). Twenty healthy volunteers were shown each colour-edited plate. The answers they reported were compared with what would be expected for that colour-simulation scenario based on the answer key provided in the Ishihara booklet ("expected" answer). There were nine plates that had comparable patterns between the EHB and Ishihara test. We found no significant difference in the overall proportion of "expected" answers for the full colour (p = .35), 32 bit-greyscale (p = .39) and blue channel (p = .22) conditions. There were significant differences between the proportion of "expected" answers among six individual colour- edited plates (p < .05 for each). Colour vision assessment from the EHB is distinct from comparable Ishihara plates. Clinical scenarios that require serial assessment of colour vision may benefit from using the same modality consistently rather than exchanging between the two tests with the assumption of equivalence. Refinement of digital colour editing techniques beyond 32-bit greyscale and RGB channel splitting is necessary in order to accurately simulate colour vision deficiency.

No association between cortical lesions and leptomeningeal enhancement on 7-Tesla MRI in multiple sclerosis.

BACKGROUND: Autopsy data suggest a causative link between meningeal inflammation and cortical lesions (CLs) in multiple sclerosis (MS). OBJECTIVE: To use leptomeningeal enhancement (LME) and CLs on 7-Tesla (7T) magnetic resonance imaging (MRI) to investigate associations between meningeal inflammation and cortical pathology. METHODS: Forty-one participants with MS underwent 7T MRI of the brain. CLs and foci of LME were quantified. RESULTS: All MS participants had CLs; 27 (65.8%) had >1 focus of LME. Except for hippocampal CL count (ρ = 0.32 with spread/fill-sulcal pattern LME, p = 0.042), no significant correlations were seen between LME and CLs. Mean cortical thickness correlated with the number of LME foci (ρ = -0.43, p = 0.005). Participants with relapsing-remitting multiple sclerosis (RRMS) showed no correlation with neocortical CLs, but significant correlations were seen between LME and hippocampal lesion count (ρ = 0.39, p = 0.030), normalized cortical gray matter (GM) volume (ρ = -0.49, p = 0.005), and mean cortical thickness (ρ = -0.59, p < 0.001). CONCLUSION: This study supports a relationship between LME and cortical GM atrophy but does not support an association of LME and neocortical CLs. This may indicate that meningeal inflammation is involved with neurodegenerative inflammatory processes, rather than focal lesion development.

Comparison of a Smartphone Application with Ishihara Pseudoisochromatic Plate for Testing Colour Vision.

The Eye Handbook (EHB) is the most frequently downloaded smartphone application with diagnostic tools for eye-care providers. However, limited data exists validating the EHB test to gold standard colour vision testing. EHB and Ishihara colour vision tests were evaluated and compared under simulated colour vision loss through use of image processing software. Images of both tests were processed through ImageJ to 32 bit-grey scale and blue channel under split RBG channel to model total colour vision loss and red-green (R-G) deficiency, respectively. Two colour plates differentiated R-G deficiency from total colour blindness in EHB compared with eight Ishihara plates. Without colour information, correct numerals were identified in 3.5/15 EHB plates converted to 32-bit greyscale, versus 1/16 in Ishihara. We conclude EHB may underestimate colour vision loss severity in persons with normal contrast sensitivity compared to Ishihara. Eye-care providers need to be aware of the potential inconsistency compared to standardised methods, including limitations in differentiating patients with R-G colour deficiencies from total colour blindness.

Techniques, Outcomes, and Complications of Preloaded, Trifolded Descemet Membrane Endothelial Keratoplasty Using the DMEK EndoGlide.

PURPOSE: To describe 2 insertion techniques, outcomes, and complications of preloaded, trifolded Descemet membrane endothelial keratoplasty (DMEK) cases using the DMEK EndoGlide inserter. METHODS: This retrospective, consecutive case series analyzed the first 35 cases using the DMEK EndoGlide performed between October 2018 and October 2019 at a single center. Preloaded, trifolded DMEK tissues were delivered through a fluid-injected or pull-through technique. To inject the tissue, a burst of fluid was delivered into the lumen of the injector with a second instrument. Postoperatively, best-spectacle corrected visual acuity (BSCVA), pachymetry, graft survival, and complications were assessed. RESULTS: Thirty-five eyes of 29 patients underwent DMEK alone (n = 11), with cataract surgery (n = 21), or with additional surgeries (n = 3). Of these, 19 (54.3%) grafts were injected. Video analysis revealed a median time of 3.5 minutes from graft insertion to opening for gas insertion. Median preoperative BSCVA of 0.398 logMAR improved to 0.097 logMAR (P = 0.02) at 9 months. Median pachymetry decreased from 619 µm to 551 µm (P = 0.03) at 9 months. Median donor endothelial cell count of 2890.5 cells/mm2 reduced to 2123 cells/mm2 (26.6% endothelial cell loss; P = 0.008) 6 months postoperatively. One (2.9%) graft failed due to inverted marking at the eye bank and subsequent reverse implantation. CONCLUSIONS: Pre-loaded, tri-folded tissues can be implanted with acceptable levels of endothelial cell loss. We describe a no-touch method of injecting pre-loaded, tri-folded tissue and highlight incorrect marking as a potential complication. This may not be identifiable intraoperatively due to lack of scroll formation.

Thanking you while fading away.

Presents a poem that is written from the perspective of a dying patient who is thanking the medical team that attempts to resuscitate them. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Qualitative and Quantitative Analysis of the Corneal Endothelium With Smartphone Specular Microscopy.

PURPOSE: We sought to demonstrate the feasibility of a lower-cost, portable method for qualitative and quantitative analysis of the corneal endothelium using a smartphone and slit-lamp biomicroscope. METHODS: In this study, at a single academic center, we recruited healthy participants to undergo imaging of the corneal endothelium using both a smartphone-based method and a specular microscope. Participants first had their eyes imaged with a CellChek NSP-9900 Specular Microscope (Konan Medical, Inc, Irvine, CA). For image capture on the smartphone, a beam of light approximately 0.2 mm in diameter was directed to the center of the cornea with a slit-lamp biomicroscope to achieve specular reflection. With 40× zoom on the slit-lamp and 4K video mode set on an iPhone 7 Plus held to an ocular, the corneal endothelium was recorded until the hexagonal pattern of cells was identified and the sharpest frame from the video was selected. RESULTS: The videos were analyzed from 14 sets of eyes (average length 2 minutes 40 seconds). The average intraclass correlation coefficient was 0.67 (95% confidence interval, 0.43-0.82). The mean difference between smartphone endothelial cell count and specular endothelial cell count was -209 cells/mm (SD = 483 cells/mm), which did not achieve significance (P = 0.14). A Bland-Altman analysis with simple linear regression showed no proportional bias when comparing the 2 modalities (coefficient = -0.20; t-value = -0.42; P = 0.68). CONCLUSIONS: Smartphone specular microscopy is capable of qualitative and quantitative analysis of the corneal endothelium. Further refinement to standardize the light source and automate analysis will increase feasibility.

Clinical Outcomes Of Descemet Membrane Endothelial Keratoplasty Using The Bonfadini-Todd Injector For Graft Insertion.

PURPOSE: To evaluate the clinical outcomes of using an Alcon intraocular lens (IOL) B cartridge for graft insertion during Descemet membrane endothelial keratoplasty (DMEK). PATIENTS AND METHODS: We retrospectively reviewed medical charts of patients who underwent DMEK using the Bonfadini-Todd injector, composed of an Alcon IOL B cartridge connected to plastic tubing and a syringe, for graft insertion between May 2016 and August 2018. Patient demographics, diagnoses, donor information, visual acuity, intraocular pressure (IOP), graft position and attachment status, pachymetry, and postoperative complications were recorded. RESULTS: Twenty-four eyes of 23 patients with an average age of 72.8 ± 10.0 years (range, 48-87 years) were included. Mean follow-up duration was 13.3 ± 6.6 months (range, 3-26 months). Twenty-one (87.5%) patients had a primary diagnosis of Fuchs endothelial dystrophy, two (8.3%) patients had bullous keratopathy and one (4.2%) had Peter's anomaly. Sixteen (66.7%) cases combined phacoemulsification and IOL implantation. Best-corrected visual acuity improved from a median of 0.398 logMAR preoperatively to 0.097 logMAR (P <0.001) at last follow-up examination, and central corneal thickness decreased from a median of 651 µm to 533.5 µm (P <0.001). Nine of 24 patients (37.5%) required re-bubbling due to partial graft detachment with a mean time of 12.1 ± 9.2 days (range, 5-35 days). One patient (4.2%) developed graft failure after re-bubbling and underwent Descemet stripping endothelial keratoplasty. CONCLUSION: The Alcon IOL B cartridge for DMEK graft insertion is safe and simple.

Opioid tolerance impacts compliance with enhanced recovery pathway after major abdominal surgery.

BACKGROUND: Opioid tolerant patients have been shown to have poor postoperative outcomes. Enhanced recovery pathways are evidence-based interventions that focus on optimizing recovery, and their effectiveness depends on the degree of compliance with the pathway. We wish to determine pathway compliance and its impact on postoperative outcomes in opioid tolerant patients undergoing abdominal surgery on an enhanced recovery pathway. METHODS: From December 2014 to June 2017, 646 patients undergoing major abdominal surgery on an enhanced recovery pathway were included. Patients <18 years and having emergency surgery were excluded. Compliance was measured to 14 perioperative pathway standards and high-compliance was defined as adhering to ≥75% standards. Opioid tolerance was defined as any patient taking a prescribed opioid medication equivalent to 60 mg of oral morphine per day for 1 week prior to surgery. The Colorectal Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity was used for risk-adjusted analyses. Outcomes of interest include length of stay, major complications (Clavien-Dindo ≥2), 30-day readmission rates, and mortality. RESULTS: Overall, 114 (18%) patients were opioid tolerant and 532 (82%) were not opioid tolerant. Opioid tolerant patients were less likely to be highly compliant with enhanced recovery pathway standards than non-tolerant patients (35% vs 54%; P < .001); particularly postoperative care standards. On adjusted analysis, opioid tolerance was associated with a 2-fold increase in readmissions following major abdominal surgery. Examining only those patients with opioid tolerance, adjusted analysis demonstrated that high compliance with the enhanced recovery pathway standards was independently associated with a 26% reduction in length of stay, over a 90% reduction in major complications, and mitigated the effect on readmissions. CONCLUSION: The authors provide evidence that opioid tolerance is associated with less favorable outcomes in patients undergoing major abdominal surgery on an enhanced recovery pathway, and this is likely due to a lack of pathway compliance. Establishing strategies to improve compliance in this challenging patient cohort may serve to mitigate the negative impact of opioid tolerance.

Aspiration of Tri-folded, Endothelium-In Grafts for Descemet Membrane Endothelial Keratoplasty.

PURPOSE: In Descemet membrane endothelial keratoplasty (DMEK), loading and positioning of tri-folded grafts into a cartridge is generally conducted with forceps or a hook, risking graft tear or trauma. We demonstrate the feasibility of loading tri-folded grafts into a cartridge with no touch to the endothelium required beyond the tri-folding process. METHODS: A corneoscleral rim with a prestripped DMEK graft is placed into a petri dish. After the graft is tri-folded with forceps and removed from its stromal attachment, the graft is gently wicked into the tip of a saline-filled Alcon B IOL cartridge connected to IV extension tubing and a 3 cc syringe, drawn into the cartridge by positioning it adjacent to the graft tip. The remainder of the graft is aspirated with the addition of saline. The cartridge orientation is reversed for graft injection. In this retrospective analysis, we analyzed surgical videos for preparation times, and assessed postoperative visual acuity, pachymetry, and endothelial cell density. RESULTS: Thirteen cases underwent this approach. Median preparation time from stain to cartridge eye contact was 8.5 minutes, and time from graft injection to final centration and bubbling was 2.9 minutes. Corneal thickness decreased from a median of 623 microns preoperatively to 566 µm at 1 month (P = 0.038). Visual acuity improved by 1 month by a median of 0.3 logarithm of the minimum angle of resolution (logMAR) (P = 0.016). Endothelial cell density decreased by 32.4% at 1 month compared with baseline. CONCLUSIONS: Endothelium-in DMEK grafts may be loaded into a plastic cartridge using a skill set similar to aspiration of a scroll.