Flipped Classroom Case Learning vs Traditional Lecture-Based Learning in Medical School Ophthalmology Education: A Randomized Trial.

PURPOSE: To address the problem of teaching noncore specialties, for which there is often limited teaching time and low student engagement, a flipped classroom case learning (FCCL) module was designed and implemented in a compulsory 5-day ophthalmology rotation for undergraduate medical students. The module consisted of a flipped classroom, online gamified clinical cases, and case-based learning. METHOD: Final-year medical students in a 5-day ophthalmology rotation were randomized to the FCCL or a traditional lecture-based (TLB) module. The outcomes of subjective assessments (student-rated anonymous Likert scale questionnaire, scale 1 to 5, and course and teaching evaluation, scale 1 to 6) and objective assessments (end-of-rotation and post-MBChB multiple-choice questions, scale 0 to 60) were compared between the 2 groups. RESULTS: Between May 2021 and June 2022, 216 students (108 in each group) completed the study. Compared with the TLB students, the students in the FCCL group rated various aspects of the course statistically significantly higher, including feeling more enthusiastic and engaged by the course and more encouraged to ask questions and participate in discussions (all P < .001). They also gave higher ratings for the instructional methods, course assignments, course outcomes, and course workload ( P < .001). They gave higher course and teaching evaluation scores to the tutors (5.7 ± 0.6 vs 5.0 ± 1.0, P < .001). The FCCL group scored higher than the TLB group on the end-of-rotation multiple-choice questions (53.6 ± 3.1 vs 51.8 ± 2.8, P < .001). When 32 FCCL students and 36 TLB students were reassessed approximately 20 weeks after the rotation, the FCCL group scored higher (40.3 ± 9.1) than the TLB group (34.3 ± 10.9, P = .018). CONCLUSIONS: Applying the FCCL module in ophthalmology teaching enhanced medical students' satisfaction, examination performance, and knowledge retention. A similar model may be suitable for other specialties.

Bilateral synchronous conjunctival myxoma and review of the literature.

PURPOSE: The purpose of this study was to report the clinicopathological features and management of the first case of bilateral synchronous conjunctival myxoma. METHODS: This study was a case report and literature review. RESULTS: A 66-year-old Chinese male with past ocular history of uncomplicated bilateral phacoemulsification and intraocular lens (IOLs) 3 years ago prior to presentation presented with bilateral red and swollen conjunctiva for over a year. On examination his corrected distance visual acuity (CDVA) was 25/20 in the right eye 20/20 in the left eye. Slit lamp examination revealed swollen temporal conjunctiva bilaterally which appeared as painless, well-circumscribed, salmon-pink, fleshy patches. The lesion in the right eye was subsequently excised, followed by excision of the lesion in the left eye at 3-week interval. Microscopically, histopathological examination of both excised specimens revealed hypocellular conjunctival mucosa covered by non-dysplastic epithelium, with presence of myxoid degeneration in the subepithelial stroma and immunostaining findings consistent with conjunctival myxoma. At his latest follow-up at 24 months, there were no recurrences of the conjunctival masses and the CDVA was the same as preoperatively.

Minimally Invasive Glaucoma Surgery in Primary Angle-Closure Glaucoma.

Primary angle-closure glaucoma (PACG) is responsible for half of the glaucoma-related blindness worldwide. Cataract surgery with or without trabeculectomy has been considered to be the first-line treatment in eyes with medically uncontrolled PACG. While minimally invasive glaucoma surgery has become an important surgical approach for primary open-angle glaucoma, its indications and benefits in PACG are less clear. This review summarizes the efficacy and safety profile of minimally invasive glaucoma surgery in PACG to unfold new insights into the surgical management of PACG.

Wavefront aberrometry repeatability and agreement-A comparison between Pentacam AXL Wave, iTrace and OPD-Scan III.

INTRODUCTION: To compare intrasession agreement and repeatability of wavefront aberration measurements from three different aberrometers obtained using Hartmann-Shack, ray tracing and automated retinoscopy methods, as well as their interdevice agreement. METHODS: Three consecutive measurements were obtained using the Pentacam AXL Wave, the iTrace and the OPD-Scan III in 47 eyes of 47 patients. Wavefront refractions, root mean square of total aberrations (RMS total), RMS of higher-order aberrations (HOA) and second-, third- and fourth-order HOAs were exported for 4-mm pupils. Wavefront refractions were converted into vector components: M, J0 and J45 . Intrasession agreement and repeatability were evaluated using intraclass correlation coefficients (ICCs) and repeatability coefficients (RCs); interdevice agreement was assessed using the Bland-Altman method. RESULTS: The intrasession agreement and repeatability of RMS HOA were comparable between the three devices; both the Pentacam AXL Wave and the OPD-Scan III had better intrasession agreement and repeatability for the RMS total than the iTrace (p ≤ 0.02). Intrasession repeatability for the majority of second- and third-order aberrations was better on the Pentacam AXL Wave than on the iTrace (p ≤ 0.01) and OPD-Scan III (p ≤ 0.04), although their agreement and repeatability in spherical aberration were comparable (p ≥ 0.24). Significant systematic differences and proportional bias were detected for almost all refraction power vectors and Zernike coefficients among the three devices. CONCLUSIONS: In this study, all three devices provided good-to-excellent agreement for aberration measurements. Most of the individual Zernike's components were not exchangeable between different aberrometers. Their relative intrasession performance in agreement and repeatability varied significantly across different ocular aberration parameters.

Jinhua Qinggan granules for non-hospitalized COVID-19 patients: A double-blind, placebo-controlled, and randomized controlled trial.

Background: Key findings from the World Health Organization Expert Meeting on Evaluation of Traditional Chinese Medicine (TCM) in treating coronavirus disease 2019 (COVID-19) reported that TCMs are beneficial, particularly for mild-to-moderate cases. The efficacy of Jinhua Qinggan granules (JHQG) in COVID-19 patients with mild symptoms has yet to be clearly defined. Methods: We conducted a phase 2/3, double-blind, randomized, placebo-controlled trial to evaluate the efficacy and safety of treatment with JHQG in mild, non-hospitalized, laboratory-confirmed COVID-19 patients. Participants were randomly assigned to receive 5 g/sacket of JHQG or placebo granules orally thrice daily for 10 days. The primary outcomes were the improvement in clinical symptoms and a proportion tested negative on viral polymerase chain reaction (PCR) after treatment. Secondary outcomes were the time to recover from clinical symptoms and changes in white blood cells (WBC) and acute phase reactants (C-reactive protein (CRP) and ferritin) on the 10th day after treatment initiation. Results: A total of 300 patients were randomly assigned to receive JHQG (150 patients) and placebo (150 patients). Baseline characteristics were similar in the two groups. In the modified intention-to-treat analysis, JHQG showed greater clinical efficacy (82.67%) on the 10th day of the trial compared with the placebo group (10.74%; rate difference: 71.93%; 95% CI 64.09-79.76). The proportion of patients with a negative PCR after treatment was comparable (rate difference: -4.67%; 95% CI -15.76 to 6.42). In contrast, all changes in WBC, ferritin, and CRP levels showed a statistically significant decline in JHQG (P ≤ 0.044) after treatment, but not the latter in placebo (P = 0.077). The median time to recovery of COVID-19-related symptoms including cough, sputum, sore throat, dyspnea, headache, nasal obstruction, fatigue, and myalgia was shorter in the JHQG group compared to the placebo group (P < 0.001 for all). Three patients experienced mild-to-moderate adverse events (AEs) duringthe treatment period in the JHQG group. Findings were similar between the modified intention-to-treat and the per-protocol analysis that included only patients who reported 100% adherence to the assigned regimen. Conclusion: Based on the time to recover from the COVID-19-related symptoms and AEs, it is concluded that JHQG is a safe and effective TCM for symptomatic relief of patients with mild COVID-19. A symptomatic improvement in the JHQG group patients was observed and JHQG use would have important public health implications in such patients. Clinical Trial Registration: The Trial was prospectively registered on www.clinicaltrials.gov with registration number: NCT04723524.

Accelerated corneal collagen cross-linking in progressive keratoconus: Five-year results and predictors of visual and topographic outcomes.

Purpose: To analyze the 5-year results of accelerated corneal collagen crosslinking (CXL) for progressive keratoconus and identify preoperative characteristics predictive of visual and topographic outcomes. Methods: A prospective interventional case series. Nineteen eyes of 19 patients receiving accelerated CXL with settings of 18 mW/cm2 for 5 min were included. Clinical and topographic parameters were assessed. Linear regression and logistic regression were used to compare the R2 and odds ratio (OR), respectively, between baseline characteristics and postoperative outcomes. Results: Corrected distance visual acuity (CDVA) remained stable from 0.28 ± 0.21 to 0.25 ± 0.18 logMAR (P = 0.486). The mean cylindrical refraction was stable (P = 0.119). The maximal keratometry (Kmax) decreased from 61.99 ± 10.37 to 59.25 ± 7.75 D (P < 0.001), flattening in the flattest and steepest meridians and mean keratometry were also observed (P ≤ 0.040). The mean anterior elevation at the apex reduced from 21.42 ± 16.69 to 18.53 ± 12.74 µm (P = 0.013) and changes in posterior elevation were non-significant (P = 0.629). Preoperative Kmax best predicted the postoperative change in Kmax (R2 = 0.55, P < 0.001) compared to the other baseline characteristics (P ≤ 0.028), whereas preoperative CDVA was the only significant predictor of postoperative change in CDVA (R2 = 0.41, P = 0.003). Accelerated CXL is less likely to fail in eyes with a steeper preoperative Kmax (OR = 0.74, P = 0.040) or greater posterior elevation at the apex (OR = 0.91, P = 0.042). Conclusion: Kmax significantly decreased following accelerated CXL. Eyes with worse preoperative CDVA and higher Kmax were more likely to have an improvement in visual acuity and corneal flattening.

Enhanced Monofocal Versus Conventional Monofocal Intraocular Lens in Cataract Surgery: A Meta-analysis.

PURPOSE: To compare different outcomes of an enhanced monofocal intraocular lens (IOL) versus a conventional monofocal IOL implantation after cataract surgery. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline was used for abstracting data and assessing quality. Comparative studies between enhanced monofocal versus conventional monofocal IOL implantations reporting outcomes in monocular and binocular visual acuities at various distances, spectacle independence, contrast sensitivity, optical quality, and adverse effects were identified from three databases. Meta-analysis, sensitivity analysis, and subgroup analysis were performed. RESULTS: A total of 680 eyes implanted with an enhanced monofocal IOL (Tecnis Eyhance ICB00; Johnson & Johnson) and 647 eyes with a conventional monofocal IOL from 3 randomized controlled trials and 9 comparative studies were included. The enhanced monofocal IOL showed better monocular uncorrected intermediate visual acuity (UIVA) (mean difference [MD]: -0.11 logMAR; 95% CI: -0.12 to -0.09), binocular UIVA (MD: -0.17 logMAR; 95% CI: -0.23 to -0.11), and binocular uncorrected near visual acuity performance (MD: -0.17 logMAR; 95% CI: -0.29 to -0.04) than the conventional monofocal IOL. More patients were spectacle free at intermediate distance with the enhanced monofocal IOL (odds ratio: 12.9; 95% CI: 6.2 to 27.0). Both monocular (MD: -0.002 logMAR; 95% CI: -0.01 to 0.01) and binocular (MD: 0.01 logMAR; 95% CI: -0.02 to 0.03) uncorrected distance visual acuity revealed non-significant differences between the IOL designs. Contrast sensitivity, photic phenomenon, and adverse effects were comparable. CONCLUSIONS: Enhanced monofocal IOLs effectively improved unaided intermediate vision with similar distance performance relative to conventional monofocal IOLs. This was achieved without compromising the contrast sensitivity or inducing photic phenomena. [J Refract Surg. 2022;38(8):538-546.].

Combined accelerated collagen crosslinking and sub-Bowman's keratomileusis in high myopic eyes: a comparison between total ultraviolet energy dose.

AIM: To compare the safety, efficacy, and predictability outcomes of combined sub-Bowman's keratomileusis (thin flap laser in situ keratomileusis [LASIK]) and accelerated crosslinking (CXL) using two different irradiation durations. METHODS: A retrospective comparative study of patients with percent tissue altered ≥35%, undergoing simultaneous CXL during sub-Bowman's keratomileusis were recruited. Following riboflavin application, they underwent ultraviolet-A (UVA) irradiation (18 mW/cm2) for either 2 min (total energy 2.16 J/cm2) or 3 min (total energy 3.24 J/cm2). Visual and refractive outcomes were compared between follow-up visits during the first year postoperatively. Demarcation line and endothelial cell count were evaluated, respectively, at 1 and 3 months postoperatively. RESULTS: The baseline characteristics were similar between the 40 eyes/patients treated using the 2-min protocol and the 33 eyes/patients treated with the 3-min protocol (p ≥ .114). Uncorrected distance visual acuity and corrected distance visual acuity were significantly better for eyes treated with the shorter irradiation protocol on Day 1 (p ≤ .030) and Month 1 (p ≤ .040) postoperatively; these differences diminished by Month 3 (p ≥ .070). Likewise, the efficacy index was higher during the first postoperative week for the 2-min protocol (p ≤ .043). At 1 year, the proportion of eye attaining within 0.5 D of target refraction was 80.0% and 84.8% for the 2-min and 3-min protocols, respectively (p = .590). The corresponding corneal stromal demarcation line depth and endothelial cell density changes were comparable between the two groups (p = .311 and 0.899, respectively). CONCLUSIONS: A comparable volume of crosslinked corneal tissue can be achieved by using a shorter UVA irradiation duration. Additional duration of UVA irradiation could lead to delay in visual rehabilitation after simultaneous sub-Bowman's keratomileusis and CXL.

Outcomes and prognostic factors of cataract surgery in cytomegalovirus-related anterior uveitis.

PURPOSE: To evaluate the outcomes of cataract surgery in patients with cytomegalovirus (CMV) anterior uveitis and factors associated with final visual outcome. SETTING: Hong Kong Eye Hospital, Hong Kong. DESIGN: Retrospective case series. METHODS: History, clinical characteristics, corrected distance visual acuity (CDVA), medications, and complications of CMV anterior uveitic eyes that underwent cataract surgery between 2010 and 2020 were reviewed. RESULTS: This study included 26 eyes of 26 patients undergoing phacoemulsification. The median duration of disease was 4.8 years, and the median quiescent period preoperatively was 2.3 years. None required pupil manipulation or had significant intraoperative complications. The median CDVA improved from 20/100 (interquartile range [IQR] 20/200 to 20/50) preoperatively to 20/30 (IQR 20/40 to 20/25) at 1 year and 20/35 (IQR 20/50 to 20/30) at the last follow-up at a median of 4.9 years postoperatively ( P < .001). CDVA improved in 19 eyes (73.1%) and was ≥20/40 in 18 eyes (69.2%). In the multivariate regression model, preoperative use of topical 0.15% ganciclovir (ß = 0.33, 95% CI 0.17 to 0.48, P < .001) and adjunctive intraoperative intracameral dexamethasone 0.4 mg (ß = 0.19, 95% CI 0.01 to 0.36, P = .043) were associated with a better final CDVA. Loss of CDVA and poor postoperative CDVA visual acuity were mostly attributed to uveitic glaucoma, but preoperative glaucoma or the number of antiglaucoma medications did not affect final CDVA. CONCLUSIONS: Cataract surgery in eyes with CMV anterior uveitis was safe and CDVA significantly improved and remained sustained postoperatively. Topical ganciclovir 0.15% preoperatively and intracameral corticosteroid intraoperatively seem to maximize the final visual outcome.

Late-Onset Nontuberculous Mycobacterial Keratitis After Small Incision Lenticule Extraction.

PURPOSE: The purpose of this article was to report a case of unilateral late-onset nontuberculous mycobacterial keratitis after small incision lenticule extraction (SMILE). METHODS: This was a case report. RESULTS: A 27-year-old woman presented with Mycobacterium chelonae keratitis 3 weeks after uncomplicated SMILE with a solitary interface infiltrate. The keratitis worsened after an initial response to topical fortified and interface antibiotic irrigation. Despite repeated interface irrigation and topical and oral antibiotics, progressive, diffuse stromal infiltrates followed by melting of the cap ensued over the next 6 weeks. Cap amputation and intrastromal antibiotic injection followed by prolonged topical and oral antibiotics usage for the following 5 weeks led to infiltrate resolution and re-epithelization of the residual stromal bed. All medications were tapered off over 6 months after initial presentation without recurrence, but anterior stromal scarring and corneal neovascularization persisted. CONCLUSIONS: Cap amputation and intrastromal antibiotic injection for intractable post-SMILE keratitis can prevent the need for therapeutic keratoplasty.

Ocular surface disturbance in patients after acute COVID-19.

BACKGROUND: We investigated the ocular surface disturbances in COVID-19 patients discharged from the hospital. METHODS: One hundred and seventy-nine eyes of 109 healthy participants and 456 eyes of 228 post-COVID-19 patients received comprehensive eye examinations; the latter were interviewed with questionnaires on ocular symptoms before and after COVID-19 diagnosis. Associations of ocular surface manifestations with virological and ophthalmic parameters were evaluated by multivariable mixed linear or logistic regression models. RESULTS: Mean interval between COVID-19 diagnosis and ophthalmic evaluation was 52.23 ± 16.12 days. The severity of meibomian gland dysfunction (MGD) based on clinical staging was higher in post-COVID-19 than healthy eyes (1.14 ± 0.67 vs. 0.92 ± 0.68, p = 0.002) and so was ocular surface staining score (0.60 ± 0.69 vs. 0.49 ± 0.68, p = 0.044). Patients requiring supplementary oxygen during hospitalisation had shorter tear break-up time (ß -1.63, 95% CI -2.61 to -0.65). Cycle threshold (Ct) value from upper respiratory samples (inversely correlated with viral load) at diagnosis had an OR = 0.91 (95% CI 0.84-0.98) with new ocular surface symptoms 4 weeks after diagnosis. The presence of ocular surface symptoms 1 week prior to COVID-19 diagnosis showed an OR of 20.89 (95% CI 6.35-68.66) of persistent or new ocular symptoms 4 weeks afterward. CONCLUSIONS: MGD and ocular surface staining are more common and severe in post-COVID-19 patients. Patients with higher viral loads have greater risks of ocular surface symptoms. Patients requiring supplementary oxygen are more likely to show tear film instability. Ocular surface evaluation should be considered 1-3 months following hospital discharge for any COVID-19 patient.

Toric intraocular lenses for astigmatism correction after keratoplasty in phakic and pseudophakic eyes.

Residual astigmatism and anisometropia significantly affect patients' vision and quality of life even in clear grafts after corneal transplant. This study reviewed and summarized the role of toric intraocular lenses (IOLs) in phakic and pseudophakic eyes after penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty in correcting residual astigmatism. 342 eyes from 20 studies with iris-clipped toric IOL, ciliary sulcus toric implantable collamer lens, piggyback sulcus toric IOL, or posterior chamber toric IOL implantations for phakic, pseudophakic, or eyes undergoing cataract surgery after keratoplasty were included. Visual, refractive, and predictability outcomes were encouraging. Secondary realignment rate and complications were low. Endothelial cell loss secondary to phakic toric IOLs might be a concern over the long-term, particularly in iris-clipped IOLs in PKP eyes. Toric IOLs represent a viable option in the treatment of residual astigmatism in postkeratoplasty eyes, resulting in improved visual acuity and reduced anisometropia.

Diagnostic assessment of glaucoma and non-glaucomatous optic neuropathies via optical texture analysis of the retinal nerve fibre layer.

The clinical diagnostic evaluation of optic neuropathies relies on the analysis of the thickness of the retinal nerve fibre layer (RNFL) by optical coherence tomography (OCT). However, false positives and false negatives in the detection of RNFL abnormalities are common. Here we show that an algorithm integrating measurements of RNFL thickness and reflectance from standard wide-field OCT scans can be used to uncover the trajectories and optical texture of individual axonal fibre bundles in the retina and to discern distinctive patterns of loss of axonal fibre bundles in glaucoma, compressive optic neuropathy, optic neuritis and non-arteritic anterior ischaemic optic neuropathy. Such optical texture analysis can detect focal RNFL defects in early optic neuropathy, as well as residual axonal fibre bundles in end-stage optic neuropathy that were indiscernible by conventional OCT analysis and by red-free RNFL photography. In a diagnostic-performance study, optical texture analysis of the RNFL outperformed conventional OCT in the detection of glaucoma, as defined by visual-field testing or red-free photography. Our findings show that optical texture analysis of the RNFL for the detection of optic neuropathies is highly sensitive and specific.

Nicotinamide riboside as a neuroprotective therapy for glaucoma: study protocol for a randomized, double-blind, placebo-control trial.

BACKGROUND: Whereas lowering the intraocular pressure (IOP) can slow optic nerve degeneration in glaucoma, many patients with glaucoma continue to develop progressive loss in vision despite a significant reduction in IOP. No treatment has been shown to be effective for neuroprotection in glaucoma. We set out to conduct a randomized controlled trial to investigate whether nicotinamide riboside (NR), a nicotinamide adenine dinucleotide precursor, is effective to slow optic nerve degeneration in patients with primary open-angle glaucoma (POAG). We hypothesize that patients treated with NR have a slower rate of progressive retinal nerve fiber layer (RNFL) thinning compared with those treated with placebo. METHODS: This is a randomized, double-blind, placebo-controlled, parallel-group, multi-center study including 125 patients with POAG. Patients will be randomized to receive 300 mg NR or placebo for 24 months. Clinical examination, optical coherence tomography imaging of the RNFL, and visual field (VF) test will be performed at the baseline, 1 month, 4 months, and then at 2-month intervals until 24 months. The primary outcome measure is the rate of RNFL thinning measured over 24 months. The secondary outcome measures include (1) time to VF progression, (2) time to progressive RNFL/ganglion cell inner plexiform layer (GCIPL) thinning, and (3) the rate of change of VF sensitivity over 24 months (to investigate neuroprotection) and 1 month (to investigate neuroenhancement). The rates of RNFL thinning and VF sensitivity decline between treatment groups will be compared with linear mixed modeling. Survival analysis will be performed to compare the differences in time from baseline to VF progression and time from baseline to progressive RNFL/GCIPL thinning between treatment groups using Cox proportional hazards models. DISCUSSION: Outcome measures in glaucoma neuroprotection trials have been centered on the detection of VF progression, which may take years to develop and confirm. In addition to addressing whether NR has a neuroprotective/neuroenhancement effect in glaucoma patients, this study will demonstrate the feasibility of studying neuroprotection in a relatively short trial period (24 months) by comparing the rates of progressive RNFL thinning, a more reproducible and objective outcome measure compared with VF endpoints, between treatment groups. TRIAL REGISTRATION: Chinese Clinical Trial Registry 1900021998.

COVID-19: Update on Its Ocular Involvements, and Complications From Its Treatments and Vaccinations.

ABSTRACT: The coronavirus disease 2019 (COVID-19) came under the attention of the international medical community when China first notified the World Health Organization of a pneumonia outbreak of then-unknown etiology in Wuhan in December 2019. Since then, COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has appalled the world by spreading at a pandemic speed. Although ophthalmologists do not directly engage in the clinical care of COVID-19 patients, the ophthalmology community has become aware of the close ties between its practice and the pandemic. Not only are ophthalmologists at heightened risk of SARS-CoV-2 exposure due to their physical proximity with patients in routine ophthalmic examinations, but SARS-CoV-2 possesses ocular tropism resulting in ocular complications beyond the respiratory tract after viral exposure. Furthermore, patients could potentially suffer from adverse ocular effects in the therapeutic process. This review summarized the latest literature to cover the ophthalmic manifestations, effects of treatments, and vaccinations on the eye to aid the frontline clinicians in providing effective ophthalmic care to COVID-19 patients as the pandemic continues to evolve.