Trends and Clinical Outcomes of Fungal Keratitis in Canada: A 20-year Retrospective Multicentre Study.

PURPOSE: An increase in fungal and particularly filamentous keratitis has been observed in many geographic areas, mostly in contact lens wearers. This study seeks to characterize long-term trends in fungal keratitis in a continental climate area to provide guidance for diagnosis and treatment. DESIGN: Retrospective multicentric case series. METHODS: Cases of microbiology-confirmed fungal keratitis from 2003 to 2022 presenting to tertiary care centers across Canada were included. Charts were reviewed for patient demographics, risk factors, visual acuity, and treatments undertaken. RESULTS: A total of 138 patients were identified: 75 had yeast keratitis while 63 had filamentous keratitis. Patients with yeast keratitis had more ocular surface disease (79% vs 28%) while patients with filamentous keratitis wore more refractive contact lenses (78% vs 19%). Candida species accounted for 96% of all yeast identified, while Aspergillus (32%) and Fusarium (26%) were the most common filamentous fungi species. The mean duration of treatment was 81 ± 96 days. Patients with yeast keratitis did not have significantly improved visual acuity with medical treatment (1.8 ± 1 LogMAR to 1.9 ± 1.5 LogMAR, P = .9980), in contrast to patients with filamentous keratitis (1.4 ± 1.2 LogMAR to 1.1 ± 1.3 LogMAR, P = .0093). CONCLUSIONS: Fungal keratitis is increasing in incidence, with contact lenses emerging as one of the leading risk factors. Significant differences in the risk factors and visual outcomes exist between yeast keratitis and filamentous keratitis which may guide diagnosis and treatment.

The burden of flashes and floaters in traditional general emergency services and utilization of ophthalmology on-call consultation: a cross-sectional study.

PURPOSE: To characterize the healthcare utilization and clinical characteristics of patients presenting with flashes and/or floaters (F/F) in general emergency service (GES) settings. METHODS: All adults presenting to GESs (emergency departments (EDs) and urgent care centers (UCCs)) with symptoms of F/F in Hamilton, Ontario between Jan. 1 - Dec. 31, 2018 were reviewed. Primary outcome was the proportion of patients presenting to GESs with F/F for which ophthalmology emergency services (OESs) were consulted. Secondary outcomes included features predictive of OES consultation by logistic regression and cost of GES utilization. RESULTS: Of 6590 primary eye-related visits to GESs, 10.4% (687) involved symptoms of F/F. Mean age of patients with F/F was 57 ± 15 years, and 61% were female. Consultation rate to OESs for F/F presentations was 89% (608/687). Logistic regression identified symptoms ≤ 2 weeks (OR 8.0; 95% CI 2.3-28), ≥ 45 years age (OR 2.4; 95% CI 1.4-4.3), UCC setting (OR 2.7; 95% CI 1.6-4.6), headache (OR 0.22; 95% CI 0.12-0.41), and neurologic symptoms (OR 0.1; 95% CI 0.19-0.49) as variables predictive of OES consultation. Mean time from triage to discharge in GESs for F/F patients was 2.43 ± 2.36 h. Mean cost per visit was $139.11 ± $113.93 Canadian dollars. Patients for which OES were consulted waited a total of 1345 h in GESs and accounted for $81,879.70 in costs. CONCLUSION: Patients presenting with F/F in GESs consume considerable resources in healthcare expenditure and time spent in GESs and most receive OES consultation. Identifying these patients at triage may allow for increased efficiency for the healthcare system and patients.

Transepithelial versus Epithelium-off Corneal Collagen Cross-linking for Corneal Ectasia: A Systematic Review and Meta-analysis.

TOPIC: To evaluate the safety and efficacy of transepithelial corneal cross-linking in comparison with the established epithelium-off technique for corneal ectasia. CLINICAL RELEVANCE: Considerable debate exists regarding whether transepithelial and epithelium-off cross-linking are comparable in their safety and efficacy. METHODS: We searched 16 electronic databases, including Medline, Embase, Web of Science, and the grey literature, current to July 8, 2020, for randomized controlled trials comparing transepithelial and epithelium-off cross-linking for corneal ectasia. We excluded studies evaluating cross-linking for nonectatic indications, as well as non-randomized controlled trials. Our primary outcome was the change in maximal keratometry (Kmax) at 12 months after cross-linking, and we considered additional topographic, visual, and safety outcomes. We summarized our analyses by calculating weighted mean differences (MDs) with associated 95% confidence intervals (CIs) for continuous outcomes and relative risks (RRs) with corresponding 95% CIs for dichotomous outcomes. We conducted trial sequential analysis to determine whether the required information size was met for each outcome. The quality of individual trials was evaluated using the Cochrane Collaboration's risk of bias assessment tool, and the evidence was assessed at an outcome level using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: Twelve studies totaling 966 eyes were eligible. A significant difference was found between transepithelial and epithelium-off cross-linking groups in the change in Kmax at 12 months (MD, 0.75; 95% CI, 0.23-1.28; P = 0.004; primary outcome) and at longest follow-up (MD, 1.20; 95% CI, 0.62-1.77; P < 0.001; secondary outcome) after treatment. No significant difference was found between the 2 groups when examining uncorrected distance visual acuity (MD, 0.04; 95% CI, -0.06 to 0.14; P = 0.386) or corrected distance visual acuity (MD, 0.01; 95% CI, -0.06 to 0.09; P = 0.732). Transepithelial cross-linking was associated with significantly fewer complications than the epithelium-off approach (RR, 0.22; 95% CI, 0.06-0.79; P = 0.020), although it was associated with an increased rate of disease progression at 12 months after treatment (RR, 4.49; 95% CI, 1.24-16.25; P = 0.022). The required information size was met for our primary outcome and trial sequential analysis supported the conventional meta-analysis. The quality of evidence was rated as moderate using the Grading of Recommendations Assessment, Development, and Evaluation methodology. DISCUSSION: The efficacy of transepithelial cross-linking remains inferior to the epithelium-off approach, although it is significantly safer.

Transepithelial versus epithelium-off corneal collagen cross-linking for corneal ectasia: protocol for a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

INTRODUCTION: Corneal ectasias are progressive, degenerative ocular diseases defined by abnormal structural changes in the cornea, leading to distortion of vision and substantial reduction in quality of life. Corneal collagen cross-linking (CXL) increases the biomechanical rigidity of the cornea and has been shown to halt ectatic processes. The established CXL protocol requires removal of the corneal epithelium. However, some surgeons have proposed transepithelial approaches to enhance patient recovery and minimise adverse events. Whether novel transepithelial approaches are as effective in arresting ectasia as the established epithelium-off protocol remains unclear. This study will systematically review the evidence on transepithelial CXL approaches and compare it to the epithelium-off protocol. METHODS AND ANALYSIS: We will include randomised controlled trials (RCTs) comparing transepithelial and epithelium-off CXL for any corneal ectasia. We will search 16 electronic databases including MEDLINE and Embase, as well as the grey literature. Two reviewers will independently screen search results to identify eligible studies, complete data abstraction and conduct quality assessment. We will assess the quality of individual RCTs using the Cochrane risk of bias assessment tool. Our primary outcome will be the change in maximal keratometry at 12 months after treatment, and we will examine 11 additional outcomes. We will summarise our analyses by measures of association (relative risk or odds ratio) and corresponding 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean differences with 95% CIs for continuous outcomes. Prespecified subgroup analyses will be conducted to explore heterogeneity. The overall quality of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review as it draws from previously published data. Results of the study will be submitted to a peer-reviewed journal for publication and discussed at conferences and seminars. PROSPERO REGISTRATION NUMBER: CRD42018102069.

Discrepancies in physician-patient agreement in reporting ocular history.

OBJECTIVE: The purpose of this study was to investigate the extent of agreement between physicians and patients in reporting ocular history and to determine whether there are any predictive factors for physician-patient consensus. DESIGN: Retrospective chart review. PARTICIPANTS: Between June and September 2014, adult patients undergoing cataract surgery were recruited for the study. METHODS: Before surgery, patient demographics and self-reported ocular history were extracted from a prospectively collected database. Medical charts were retrospectively examined to retrieve physician-reported ocular history. RESULTS: One hundred and thirty-eight patients participated. Mean cohort logMAR visual acuity was 0.46 ± 0.34 (Snellen equivalent of approximately 20/60) and mean age was 74.1 ± 8.3 years. For glaucoma, Cohen's kappa revealed a moderate-to-good concordance between physicians and patients (κ = 0.604), whereas a poor-to-fair level of agreement existed in reporting maculopathy, such as age-related macular degeneration and macular holes (κ = 0.254). The logistic regression model revealed that preoperative visual acuity (p = 0.223), sex (p = 0.736), age (p = 0.910), and education (p = 0.738) were not significant predictors of physician-patient agreement. CONCLUSIONS: The accuracy of patient-reported ocular history varies by pathology. Self-reported glaucoma history is consistent between patients and physicians; however, patients under-report the diagnosis of maculopathy. Age, sex, and level of education do not appear to influence patient-reported accuracy of ocular comorbidities.

Sandwich fibrin glue technique for attachment of conjunctival autograft during pterygium surgery.

OBJECTIVE: To report the results of a sandwich application of fibrin glue compared with the standard method of using fibrin glue for the attachment of the conjunctival autograft in pterygium surgery. PARTICIPANTS: The study group consisted of 56 consecutive eyes with primary pterygium. METHODS: We performed a retrospective analysis comparing the standard method of using fibrin glue for the attachment of the conjunctival autograft during pterygium excision surgery versus the "sandwich technique." In the "sandwich technique," the thrombin component of the fibrin glue was applied after the graft was secured in position over a bed of fibrinogen. RESULTS: Graft dehiscence occurred in 3 eyes in the conventional group only. Recurrence occurred in 2 eyes in the conventional group and 1 eye in the sandwich group. None of the values reached statistical significance. CONCLUSIONS: The sandwich technique simplifies conjunctival graft fixation during pterygium surgery with conjunctival autograft by allowing more time to properly position the autograft before fibrin clot formation.

Intraocular pressure measurement by radio wave telemetry.

PURPOSE: To determine the biocompatibility of a new wireless intraocular pressure (IOP) transducer (WIT) in rabbit eyes and to correlate its measurements with other pressure-measuring devices. METHODS: The WIT is a ring-shaped intraocular device that allows wireless IOP measurements through radiofrequency. It was implanted into six eyes of New Zealand White rabbits after extracapsular lens extraction. A sham rabbit eye with no transducer implanted was used as a control. The animals were observed and examined by microscopy at various intervals up to 25 months after surgery. IOP was measured at various intervals by pneumotonometry, tonometry, WIT, and manometry. The data from the various devices were compared and analyzed for reproducibility. Two eyes were enucleated at 5.5 and 20 months after implantation and analyzed by histology. RESULTS: The WIT appears to be well tolerated in the rabbit eye, with no evidence of significant inflammation or scar formation by microscopic in vivo examination. Histology did not reveal intraocular inflammation or membrane formation. Repeated IOP measurements with pneumotonometry, tonometry, and the WIT resulted in SDs of 2.70 mm Hg, 3.35 mm Hg, and 0.81 mm Hg, respectively. The concordance between the WIT and direct manometry measurements was high. A downward drift in IOP measured by the WIT was noted in three rabbits, necessitating recalibration. CONCLUSIONS: The WIT is well tolerated by the rabbit eye. Its measurements are reproducible and in close concordance with manometry. A downward IOP drift warrants further investigation.