Optimising subjective grading of corneal staining in Sjögren's syndrome dry eye disease.

AIM: To assess whether smaller increment and regionalised subjective grading improves the repeatability of corneal fluorescein staining assessment, and to determine the neurological approach adopted for subjective grading by practitioners. METHODS: Experienced eye-care practitioners (n = 28, aged 45 ± 12 years), graded 20 full corneal staining images of patients with mild to severe Sjögren's syndrome with the Oxford grading scheme (both in 0.5 and 1.0 increments, globally and in 5 regions), expanded National Eye Institute (NEI) and SICCA Ocular Staining Score (OSS) grading scales in randomised order. This was repeated after 7-10 days. The digital images were also analysed objectively to determine staining dots, area, intensity and location (using ImageJ) for comparison. RESULTS: The Oxford grading scheme was similar with whole and half unit grading (2.77vs2.81,p = 0.145), but the variability was reduced (0.14vs0.12,p < 0.001). Regional grade was lower (p < 0.001) and more variable (p < 0.001) than global image grading (1.86 ± 0.44 for whole increment grading and 1.90 ± 0.39 for half unit increments). The correlation with global grading was high for both whole (r = 0.928,p < 0.001) and half increment (r = 0.934,p < 0.001) grading. Average grading across participants was associated with particle number and vertical position, with 74.4-80.4% of the linear variance accounted for by the digital image analysis. CONCLUSIONS: Using half unit increments with the Oxford grading scheme improve its sensitivity and repeatability in recording corneal staining. Regional grading doesn't give a comparable score and increased variability. The key neurally extracted features in assigning a subjective staining grade by clinicians were identified as the number of discrete staining locations (particles) and how close to the vertical centre was their spread, across all three scales.

Adverse drug reactions attributed to generic substitution of antiretroviral medications among HIV treatment and pre-exposure prophylaxis clients in British Columbia, Canada.

BACKGROUND: In British Columbia, antiretrovirals (ARVs) for HIV treatment (HIV-Tx) and pre-exposure prophylaxis (PrEP) are free-of-charge through publicly-funded Drug Treatment Programs (DTPs). When available, less costly generics are substituted for brand-name ARVs. We describe the incidence and type of product substitution issue (PSI) adverse drug reactions (ADRs) attributed to generic ARVs. METHODS: Cohorts included DTP clients ≥19 years who received generic ARVs for HIV-Tx (abacavir-lamivudine, emtricitabine-tenofovir DF, efavirenz-emtricitabine-tenofovir DF, atazanavir or darunavir between 01 Jun 2017 and 30 Jun 2022) or PrEP (emtricitabine-tenofovir DF, 01 Apr 2018 to 30 Jun 2022). Demographic, ARV and ADR data were extracted from DTP databases and summarized by descriptive statistics. PSI incidence was calculated for each product during the year following brand-to-generic and generic-to-generic transitions (first-year-post-rollout), and compared between generic versions using generalized estimating equations. For context, incidence of any ARV product-related ADR was calculated in the same 1-year periods. RESULTS: During first-year-post-rollout periods, 5339 HIV-Tx (83% male, median age 52 years) and 8095 PrEP (99% male, median 33 years) clients received generic ARVs, and reported 78 and 23 generic PSIs, respectively. PSI incidence was <1% for most generic ARVs, with mild-moderate symptoms including gastrointestinal upset, headache, dizziness, fatigue/malaise and skin rash. In HIV-Tx clients, the efavirenz-containing product had higher PSI incidence than other ARVs (2.2%, p = .004), due to more neuropsychiatric adverse reactions. Any ADR incidence was stable across measurement periods, and generic PSIs represented less than one third of all product-related ADRs. CONCLUSIONS: Generic substitution of antiretrovirals for HIV-Tx and PrEP was well tolerated, with ≤2% incidence of mild-moderate PSI ADRs.

Clinical and biochemical analysis of the ageing tear film.

BACKGROUND: Tear film stability is important for healthy visual function, and yet little is known of the ageing mechanisms. The aim of this study was to investigate parallels between biochemical changes and clinical physical parameters, which occur in the tear film of two subject populations differing in age by over 30 years. METHODS: Two distinct age groups were chosen: 11 'younger' (23.7±2.1 years) and 19 'older' (63.0±4.0 years) subjects. A series of clinical tests were performed to access tear volume, tear film stability and general ocular health. Tear protein analyses from extracted Schirmer strips were conducted with the Agilent 2100 Bioanalyzer. RESULTS: Clinical investigations highlighted significant differences between the age groups. For example: McMonnies scores (p=0.009) and bulbar redness (p=0.038) were higher for the older group, whereas tear meniscus height was larger (p=0.018) in the younger group. Similarly, relative plasma-derived albumin levels were higher (17.1%±12.4%) in the tears of the older, compared with the younger (5.0%±9.6%) group. A protein peak at ∼23 kDa was observed in 53% of the older group samples but in only 36% of the samples of the younger subjects (p=0.122). CONCLUSIONS: Distinct differences in tear film composition between the two age groups were observed. Parallels in terms of clinical symptoms which reflected a biochemical response (and vice versa) were found, but specific correlations between clinical measurements and biomarkers for individual subjects were not observed.

Best technique for upper lid eversion.

AIM: Lid eversion is an essential component of contact lens aftercare. Hence, this study determined the best method of lid eversion based on three criteria: comfort, speed of administration and the area of the palpebral conjunctiva exposed. METHOD: Twenty-five participants (aged 20-34) had 6 different techniques applied in random order by the same clinician on two separate occasions: three involving a cotton bud placed on the extended upper eyelid either centrally, at the top of the tarsal plate or off-centre; one using the wooden end of the bud placed at the top of the tarsal plate; one using the clinician's index finger to evert the lid; and one using a silicone rubber, finger-shaped substitute. The participants judged the degree of discomfort of each technique on a visual analogue scale. The time to complete the task was timed with a stop-watch and the area of exposed palpebral conjunctiva was captured with a digital slit lamp and assessed using image analysis. RESULTS: There was no difference between the initial lid eversion or subsequent repeat in terms of comfort (F = 0.304, p = 0.586), time to complete (F = 3.075, p = 0.092) or area exposed (F = 2.311, p = 0.142). Lid eversion using fingers alone or the silicone substitute everter were similar in comfort (p = 0.312), being the most comfortable methods, with off-centre cotton bud eversion or the wooden end of the cotton bud the least comfortable techniques (F = 17.480, p < 0.001). The quickest method to perform was the wooden end of the cotton bud, followed by the silicone everter (F = 17.522, p < 0.001). The area of exposed palpebral conjunctiva was greatest using the silicone everter (F = 28.199, p < 0.001). CONCLUSIONS: Lid eversion had repeatable results, with the silicone everter placed at the top of the tarsal plate the most comfortable for the patient, quick to perform and exposed a greater area of tarsal plate than other techniques and therefore is recommended to clinicians.

Crossover Evaluation of Silicone Hydrogel Daily Disposable Contact Lenses.

PURPOSE: To assess the surface tear breakup time and clinical performance of three daily disposable silicone hydrogel contact lenses over 16 hours of wear. METHODS: Thirty-nine patients (mean [± SD] age, 22.1 [± 3.5] years) bilaterally wore (narafilcon A, filcon II-3, and delefilcon A) contact lenses in a prospective, randomized, masked, 1-week crossover clinical trial. Tear film was assessed by the tear meniscus height (TMH), ocular/contact lens surface temperature dynamics, and lens surface noninvasive breakup time at 8, 12, and 16 hours of wear. Clinical performance and ocular physiology were assessed by subjective questionnaire, by high-/low-contrast logMAR (logarithm of the minimum angle of resolution) acuity, and through bulbar and limbal hyperemia grading. Corneal and conjunctival staining were assessed after lens removal. RESULTS: Delefilcon A demonstrated a longer noninvasive breakup time (13.4 [± 4.4] seconds) than filcon II-3 (11.6 [± 3.7] seconds; p < 0.001) and narafilcon A (12.3 [± 3.7] seconds; p < 0.001). A greater TMH (0.35 [± 0.11] mm) was shown by delefilcon A than filcon II-3 (0.32 [± 0.10] seconds; p = 0.016). Delefilcon A showed less corneal staining after 16 hours of lens wear (0.7 [± 0.6] Efron grade) than filcon II-3 (1.1 [± 0.7]; p < 0.001) and narafilcon A (0.9 [± 0.7]; p = 0.031). Time was not a significant factor for prelens tear film stability (F = 0.594, p = 0.555) or TMH (F = 0.632, p = 0.534). Lens brand did not affect temperature (F = 1.220, p = 0.308), but it decreased toward the end of the day (F = 19.497, p < 0.001). Comfort, quality of vision, visual acuity and contrast acuity, and limbal grading were similar between the lens brands but decreased with time during the day (p < 0.05). CONCLUSIONS: The tear breakup time over the contact lens surface differed between lens types and may have a role in protecting the ocular surface.

The influence of end of day silicone hydrogel daily disposable contact lens fit on ocular comfort, physiology and lens wettability.

PURPOSE: To quantify the end-of-day silicone-hydrogel daily disposable contact lens fit and its influence of on ocular comfort, physiology and lens wettability. METHODS: Thirty-nine subjects (22.1±3.5 years) were randomised to wear each of 3 silicone-hydrogel daily-disposable contact lenses (narafilcon A, delefilcon A and filcon II 3), bilaterally, for one week. Lens fit was assessed objectively using a digital video slit-lamp at 8, 12 and 16h after lens insertion. Hyperaemia, non-invasive tear break-up time, tear meniscus height and comfort were also evaluated at these timepoints, while corneal and conjunctival staining were assessed on lens removal. RESULTS: Lens fit assessments were not different between brands (P>0.05), with the exception of the movement at blink where narafilcon A was more mobile. Overall, lag reduced but push-up speed increased from 8 to 12h (P<0.05), but remained stable from 12 to 16h (P>0.05). Movement-on-blink was unaffected by wear-time (F=0.403, P=0.670). A more mobile lens fit with one brand did not indicate that person would have a more mobile fit with another brand (r=-0.06 to 0.63). Lens fit was not correlated with comfort, ocular physiology or lens wettability (P>0.01). CONCLUSIONS: Among the lenses tested, objective lens fit changed between 8h and 12h of lens wear. The weak correlation in individual lens fit between brands indicates that fit is dependent on more than ocular shape. Consequently, substitution of a different lens brand with similar parameters will not necessarily provide comparable lens fit.

An enhanced functional ability questionnaire (faVIQ) to measure the impact of rehabilitation services on the visually impaired.

AIM: To develop a short, enhanced functional ability Quality of Vision (faVIQ) instrument based on previous questionnaires employing comprehensive modern statistical techniques to ensure the use of an appropriate response scale, items and scoring of the visual related difficulties experienced by patients with visual impairment. METHODS: Items in current quality-of-life questionnaires for the visually impaired were refined by a multi-professional group and visually impaired focus groups. The resulting 76 items were completed by 293 visually impaired patients with stable vision on two occasions separated by a month. The faVIQ scores of 75 patients with no ocular pathology were compared to 75 age and gender matched patients with visual impairment. RESULTS: Rasch analysis reduced the faVIQ items to 27. Correlation to standard visual metrics was moderate (r=0.32-0.46) and to the NEI-VFQ was 0.48. The faVIQ was able to clearly discriminate between age and gender matched populations with no ocular pathology and visual impairment with an index of 0.983 and 95% sensitivity and 95% specificity using a cut off of 29. CONCLUSION: The faVIQ allows sensitive assessment of quality-of-life in the visually impaired and should support studies which evaluate the effectiveness of low vision rehabilitation services.

The significance of hand wash compliance on the transfer of dermal lipids in contact lens wear.

AIM: The aim of this study was to assess the impact of hand washing regimes on lipid transference to contact lenses. The presence of lipids on contact lenses can affect visual acuity and enhance spoilation. Additionally, they may even mediate and foster microbial transfer and serve as a marker of potential dermal contamination. METHODS AND MATERIALS: A social hand wash and the Royal College of Nursing (RCN) hand wash were investigated. A 'no-wash regime' was used as control. The transfer of lipids from the hand was assessed by Thin Layer Chromatography (TLC). Lipid transference to the contact lenses was studied through fluorescence spectroscopy (FS). RESULTS: Iodine staining, for presence of lipids, on TLC plates indicated the 'no-wash regime' score averaged at 3.4±0.8, the social wash averaged at 2.2±0.9 and the RCN averaged at 1.2±0.3 on a scale of 1-4. The FS of lipids on contact lenses for 'no washing' presented an average of 28.47±10.54 fluorescence units (FU), the social wash presented an average of 13.52±11.12 FU and the RCN wash presented a much lower average 6.47±4.26 FU. CONCLUSIONS: This work demonstrates how the method used for washing the hands can affect the concentration of lipids, and the transfer of these lipids onto contact lenses. A regime of hand washing for contact lens users should be standardised to help reduce potentially transferable species present on the hands.

A review of sexual health web sites for adolescents.

BACKGROUND: The popularity of the Internet for health information and the growing availability of online access make the Internet a compelling medium for health promotion and HIV/STI prevention efforts for adolescents. Many private and federally funded programs have incorporated Web-based approaches and online technologies into their sexual education and HIV/STI prevention efforts for adolescents. These efforts have resulted in numerous Web sites and varied online content. This content is currently understudied and underevaluated. In this study, current sexual health Web sites targeted at adolescents were catalogued and coded. METHODS: Web sites targeted at adolescents were coded for educational content, credibility, usability, as well as interactivity. RESULTS: A significant amount of sexual health information geared toward teens is available online. All the Web sites reviewed showed deficiencies in educational content, as well as deficiencies in usability, authority, and interactivity. Planned Parenthood's Web site was the most well rounded of the sites assessed.

Objective clinical performance of 'comfort-enhanced' daily disposable soft contact lenses.

PURPOSE: To examine the objective clinical performance of 'comfort-enhanced' daily disposable contact lenses over a 16-h day. METHODS: Four contact lenses (Hilafilcon B, Etafilcon A Plus, Nelfilcon A and Nelfilcon A Plus) were evaluated in an investigator masked, open label trial at the end of a week's bilateral wear. Pre-lens non-invasive tear break-up time (PL-NITBUT), tear prism height, bulbar hyperaemia and ocular surface temperature (OST) were measured with the lens in situ at 8, 12 and 16h of wear. RESULTS: There was no difference between how many hours the lenses types were worn each day (F=0.90, p=0.44). The PL-NITBUT decreased with the duration of daily lens wear (F=32.0, p<0.001) and was more stable with Nelfilcon A Plus (F=6.00, p=0.002) than with the other lenses evaluated. Bulbar blood vessels increased in coverage (F=11.5, p<0.001) but not overall redness (F=0.0, p=0.99) with the duration of daily lens wear, but there was no difference between the lenses (p>0.05). The tear prism height decreased with the duration of daily wear (F=27.0, p<0.001) and differed between lenses (F=2.9, p=0.04). The OST decreased with the duration of lens wear (F=119.7, p<0.001) and was reduced by daily disposable lens wear (F=7.88, p<0.001), but did not differ between lenses (F=0.88, p=0.45). CONCLUSIONS: Objective measures of tear film indicated a difference between the lenses evaluated for PL-NITBUT and tear prism height, but not for wearing time or bulbar conjunctival hyperaemia. Therefore clinical benefits of daily disposable 'comfort enhancing' contact lenses can be measured, but challenges remain in producing contact lenses that do not compromise anterior eye physiology over the whole day.

Simplified recording of soft contact lens fit.

PURPOSE: To determine the critical fitting characteristics of modern soft contact lens fits and from this to devise a simplified recording scheme. METHODS: Ten subjects (aged 28.1+/-7.4 years) wore eight different modern soft contact lenses. Video was captured and analysed of blink (central and up-gaze), excursion lag (up, down, right and left gaze) and push-up movement, centration and coverage. RESULTS: Lens centration was on average close to the corneal centre. Movement on blink was significantly smaller in up-gaze than in primary-gaze (p<0.001). Lag was greatest in down-gaze and least in up-gaze (p<0.001). Push-up test recovery speed was 1.32+/-0.73 mm/s. Overall lens movement was determined best by assessing horizontal lag, movement on blink in up-gaze and push-up recovery speed. Steeper lens base-curves did not have a significant effect on lens fit characteristics. Contact lens material did influence lens fit characteristics, particularly silicone-hydrogels which generally had lower centration and a faster push-up speed of recovery than HEMA lenses (p<0.05). CONCLUSION: Lag on vertical gaze, and movement on blink in primary gaze generally provide little extra information on overall lens movement compared to horizontal lag, movement on blink in up-gaze and push-up recovery speed. They can therefore be excluded from a simplified recording scheme. A simplified and comprehensive soft contact lens fit recording system could consist of a cross-hairs indicating the centre of the cornea; a circle to indicate the lens centration; a mark on the relevant position of the circle to indicate any limbal incursion; a grade (B) below for movement with blink in up-gaze, a grade (L) to the side for horizontal lag and a grade above (P) for the assessed push-up recovery speed.

Ocular motor triad with single vision contact lenses compared to spectacle lenses.

AIM: Theoretically myopes are required to exert more accommodation and vergence when wearing single vision contact lenses compared to glasses and hypermetropes less. This study aims to quantify the effects clinically. METHOD: Thirty subjects (21 female, nine male, average age 21.0+/-2.2 years) with a range of refractive errors (-7.87 D to +3.50 D) viewed in a random order, static targets at 0.1, 0.5, 1.0, 2.0, 3.0, 4.0 and 5.0 D accommodative demand that were matched for angular subtense. The subjects were fully corrected with spectacles and daily disposable contact lenses to their full prescription. Accommodation was monitored objectively with the PowerRefractor and Shin-Nippon SRW5000 and vergence and pupil size with the PowerRefractor. RESULTS: Myopes exerted greater accommodative effort for viewing near targets with contact lenses than glasses and hypermetropes less (r(2)=0.35, p=0.001 PowerRefractor). Myopes also exerted greater vergence effort for viewing near targets with contact lenses than glasses and hypermetropes less (r(2)=0.22, p<0.01). CONCLUSION: Theoretical calculation of the accommodative and vergence requirements with glasses compared to contact lenses reflect clinical findings, although there is reasonable variability between individuals.

Objective accommodative amplitude and dynamics with the 1CU accommodative intraocular lens.

PURPOSE: To compare the objective accommodative amplitude and dynamics of eyes implanted with the one-compartment-unit (1CU; HumanOptics AG, Erlangen, Germany) accommodative intraocular lenses (IOLs) with that measured subjectively. METHODS: Twenty eyes with a 1CU accommodative IOL implanted were refracted and distance and near acuity measured with a logMAR (logarithm of the minimum angle of resolution) chart. The objective accommodative stimulus-response curve for static targets between 0.17 and 4.00 D accommodative demand was measured with the SRW-5000 (Shin-Nippon Commerce Inc., Tokyo, Japan) and PowerRefractor (PlusOptiX, Nürnberg, Germany) autorefractors. Continuous objective recording of dynamic accommodation was measured with the SRW-5000, with the subject viewing a target moving from 0 to 2.50 D at 0.3 Hz through a Badal lens system. Wavefront aberrometry measures (Zywave; Bausch & Lomb, Rochester, NY) were made through undilated pupils. Subjective amplitude of accommodation was measured with the RAF (Royal Air Force accommodation and vergence measurement) rule. RESULTS: Four months after implantation best-corrected acuity was -0.01 +/- 0.16 logMAR at distance and 0.60 +/- 0.09 logMAR at near. Objectively, the static amplitude of accommodation was 0.72 +/- 0.38 D. The average dynamic amplitude of accommodation was 0.71 +/- 0.47 D, with a lag behind the target of 0.50 +/- 0.48 seconds. Aberrometry showed a decrease in power of the lens-eye combination from the center to the periphery in all subjects (on average, -0.38 +/- 0.28 D/mm). Subjective amplitude of accommodation was 2.24 +/- 0.42 D. Two years after 1CU implantation, refractive error and distance visual acuity remained relatively stable, but near visual acuity, and the subjective and objective amplitudes of accommodation decreased. CONCLUSIONS: The objective accommodating effects of the 1CU lens appear to be limited, although patients are able to track a moving target. Subjective and objective accommodation was reduced at the 2-year follow-up. The greater subjective amplitude of accommodation is likely to result from the eye's depth of focus of and the aspheric nature of the IOL.