The learning effect of the King-Devick test in semi-professional rugby union athletes.

OBJECTIVE: Abnormalities of eye movement and visual processing are common in traumatic brain injury. The King-Devick test (KDT) has been widely used in the detection and recovery of concussion. Current recommendations propose performing the initial test at baseline and then repeating annually to account for potential learning effects. In practice, this may still account for large deviations. The aim of this study was to determine the number of trials needed for a player to achieve a ceiling effect and to determine the validity of the existing protocol requiring two tests at baseline. METHODS: One hundred and eighty-three semi-professional male rugby union players (median age = 22.5 (21.0-25.3) years) were recruited. Over the duration, all athletes performed the KDT on an iPad, under standardised baseline procedures and then repeated the test based on availability during weekly in-season training. RESULTS: The improvement through each repeated trial was 0.60 ± 0.1 s (P < 0.001). The ceiling effect was determined at 30 trials. A median difference of 4.2 s (range 0-14.9) was calculated between the initial and best trial overall, although the greatest difference occurred within the first eight attempts. There was a significant positive correlation between the initial test value and the difference between first and fastest time (P < 0.001, r = 0.455). CONCLUSION: We have shown continuous improvement with repeated attempts which suggests that administrators ideally should continue to perform the KDT over the duration of the season to optimise the value of the test.

Refractive Outcomes After Trabecular Micro-Bypass Stents (iStent Inject) with Cataract Extraction in Open-Angle Glaucoma.

PURPOSE: Simultaneous cataract and glaucoma surgery has traditionally been challenging for the anterior segment surgeon. The introduction of minimally invasive glaucoma surgery (MIGS) in conjunction with cataract surgery appears safe and effective in lowering intraocular pressure. Although a significant visual impact leading from the combined procedure is unexpected, we aim to describe the refractive outcomes in a cohort of patients undergoing simultaneous cataract removal and iStent inject and discuss the potential implications of combined surgery in patients with co-existent glaucoma. PATIENTS AND METHODS: This is a retrospective consecutive case series inclusive of patients undergoing combined femtosecond laser-assisted cataract surgery and the insertion of two trabecular micro-bypass stents (iStent inject). Visual acuity, refraction and astigmatic vector analysis were collated and analysed from the preoperative and 4 weeks postoperative visits. RESULTS: One hundred and six eyes of 89 patients from 2 surgeons were included in the original cohort. The mean absolute difference from target refraction was 0.36 ± 0.25D. 73.9% of eyes were within ± 0.5D of the refractive target and 98.9% of eyes were within ± 1.00D. 73.8% of eyes had 0.5D or less residual refractive astigmatism following the procedure. CONCLUSION: We present a novel cohort of glaucoma patients undergoing combined trabecular micro-bypass stents (iStent inject) and cataract surgery achieving excellent refractive outcomes. The results of this study indicate that this second-generation device is refractively neutral.

A review of concussion diagnosis and management in Australian professional sporting codes.

Objectives: The recognition and management of concussion has become a major health concern across all sports. Despite recent attention, concussion assessment and return-to-play protocols appear to be highly variable between leading professional sporting bodies across Australia. Without readily available guidelines, players at all levels may be at risk of suboptimal management following in-game trauma. The purpose of this study was to explore the publicly available concussion guidelines of the major Australian sporting codes with an aim to identify potential opportunities to develop a national sporting consensus.Methods: Internet sites of the major sporting organizations within Australia were accessed between June 2018 to July 2018. Sites were reviewed for information pertaining to an available concussion protocol or guidelines including; concussion definition, player education documentation, requirement of baseline testing, standard concussion diagnostic measures, use of sideline testing and removal from play guidelines, return-to-play, minimum return-to-play intervals and the implementation of external evaluation of potential concussion cases.Results: Twelve sites were visited. There was consensus between many of the sporting organizations in terms of concussion definition, removal of play and sideline testing protocols. A step-wise return-to-play protocol was prevalent across most sports. A number of sporting sites however did not have readily available information.Conclusions: There is notable room for the development of concussion guidelines in Australian sport. Researchers and sporting organizations need to continuously amend current protocols to ensure this reflects best evidence-based practice.

Retinal nerve fibre changes in sports-related repetitive traumatic brain injury.

IMPORTANCE: There is limited literature on the use of optical coherence tomography in the assessment of retinal nerve fibre layer (RNFL) thickness in sports-related repetitive mild traumatic brain injury. BACKGROUND: To evaluate RNFL thickness in professional rugby league players. RNFL thinning may serve as a proxy for wider white matter degeneration. DESIGN: Cross-sectional observational study. PARTICIPANTS: Thirteen retired Australian professional rugby league players were recruited. METHODS: Participants underwent binocular optical coherence tomography to measure RNFL thickness. Each participant underwent a complete ophthalmic assessment to exclude concurrent disease. MAIN OUTCOME MEASURES: RNFL thickness of each eye were compared with a normative database. RESULTS: Participants had played professional Rugby League for 18 years on average and reported sustaining 15 sports-related concussions throughout their career. The RNFL in participants was four micrometres thinner than that of matched normative data. Cohort average RNFL thickness was reduced in 12 out of 14 optical coherence testing parameters. These findings were statistically significant in the left inferonasal [P = .013] and left nasal [P = .006] sectors. There was no statistically significant relationship between RNFL thickness and other visual measures. CONCLUSIONS AND RELEVANCE: This study is the first to demonstrate RNFL thinning in a cohort of retired Australian professional Rugby League players. RNFL changes have been shown to correlate with cerebral white matter loss and neurodegeneration. Optical coherence tomography may serve as a safe and economical means of screening for repetitive traumatic brain injury related neurodegeneration in contact sport athletes.

Persistent visual disturbances after concussion.

BACKGROUND: Ocular dysfunction, including eye movement defects, has been documented in up to 69% of patients with concussion. However, standard sports-related concussion assessment protocols do not typically include any clinical examination of the ocular system. OBJECTIVE: The aim of this article is to inform general practitioners (GPs) about ocular defects associated with concussion, identify test procedures and highlight the important role of GPs within the concussion paradigm. DISCUSSION: Ocular dysfunction that commonly occurs with concussion includes abnormalities of accommodation, convergence, saccades and smooth pursuits. This may cause blurred vision, double vision, ocular pain and difficulty with close work. Symptoms can severely affect daily work, school or play activities. Patients complaining of extended ocular symptoms following concussion should be referred to an ophthalmologist for a complete ocular assessment.

Factors Affecting Corneal Organ Culture Contamination: A 6-year Study at the New South Wales Tissue Bank.

PURPOSE: To report the rate of microbial contamination and analyze possible risk factors for contamination of banked corneas stored using the organ culture method. METHODS: Data from the New South Wales Tissue Banks incorporating the Lions NSW Eye Bank, between September 1, 2011, and November 30, 2017, were reviewed retrospectively. All corneas collected during this period and stored in organ culture storage media were tested for microbial contamination. The influence of potential factors on the rate of contamination was analyzed using the χ test and logistic regression using generalized estimating equations. RESULTS: A total of 4410 corneas were included in this study, of which 110 were medium culture positive, representing a microbial contamination rate of 2.5%. The main contaminants were Candida species followed by Staphylococcus species. Corneal tissue collected in summer and autumn had a significantly higher contamination rate (P = 0.006). All other factors studied were not shown to have a statistically significant association with contamination after accounting for within-pair correlation and confounders. CONCLUSIONS: A relatively low contamination rate of 2.5% observed in our study reflects the stringent laboratory protocols, strict donor selection criteria, and high level of experience among staff at the Lions NSW Eye Bank. Our study demonstrated that the season of collection had a strong association with the rate of organ culture contamination. Because Candida species contributed the largest percentage of contamination, specific measures to reduce and eliminate fungal proliferation should be considered by eye banks particularly in warm seasons.

Biomaterials for corneal bioengineering.

Corneal transplantation is an important surgical treatment for many common corneal diseases. However, a worldwide shortage of tissue from suitable corneal donors has meant that many people are not able to receive sight-restoring operations. In addition, rejection is a major cause of corneal transplant failure. Bioengineering corneal tissue has recently gained widespread attention. In order to facilitate corneal regeneration, a range of materials is currently being investigated. The ideal substrate requires sufficient tectonic durability, biocompatibility with cultured cellular elements, transparency, and perhaps biodegradability and clinical compliance. This review considers the anatomy and function of the native cornea as a precursor to evaluating a variety of biomaterials for corneal regeneration including key characteristics for optimal material form and function. The integration of appropriate cells with the most appropriate biomaterials is also discussed. Taken together, the information provided offers insight into the requirements for fabricating synthetic and semisynthetic corneas for in vitro modeling of tissue development and disease, pharmaceutical screening, and in vivo application for regenerative medicine.

Cue-induced reinstatement of alcohol-seeking behavior is associated with increased CaMKII T286 phosphorylation in the reward pathway of mice.

Cue-induced reinstatement of alcohol-seeking is a hallmark behavioral pathology of addiction. Evidence suggests that reinstatement (e.g., relapse), may be regulated by cell signaling systems that underlie neuroplasticity. A variety of plasticity events require activation of calcium calmodulin-dependent protein kinase II (CaMKII) in components of the reward pathway, such as the nucleus accumbens and amygdala. We sought to determine if cue-induced reinstatement of alcohol-seeking behavior is associated with changes in the activation state (e.g., phosphorylation) of CaMKII-T286. Male C57BL/6J mice (n=14) were trained to lever press on a fixed-ratio-4 schedule of sweetened alcohol (2% sucrose+9% EtOH) reinforcement. After 14-d of extinction (no cues or reinforcers), mice underwent a response-contingent reinstatement (n=7) vs. an additional day of extinction (n=7). Brains were removed immediately after the test and processed for evaluation of pCaMKII-T286 immunoreactivity (IR). Number of pCaMKII-T286 positive cells/mm2 was quantified from coronal brain sections using Bioquant Image Analysis software. Mice emitted significantly more responses on the alcohol vs. the inactive lever throughout the baseline phase with average alcohol intake of 1.1±0.03g/kg/1-h. During extinction, responses on the alcohol lever decreased to inactive lever levels by day 7. Significant cue-induced reinstatement of alcohol-seeking was observed during a single test with no effects on the inactive lever. Reinstatement was associated with increased pCaMKII-T286 IR specifically in amygdala (LA and BLA), nucleus accumbens (AcbSh), lateral septum, mediodorsal thalamus, and piriform cortex as compared to extinction control. Brain regions showing no change included the dorsal striatum, medial septum, cingulate cortex, habenula, paraventricular thalamus, and ventral hypothalamus. These results show response contingent cue-induced reinstatement of alcohol-seeking behavior is associated with selective increases in pCaMKII-T286 in specific reward- and memory-related brain regions of male C57BL/6J mice. Primary molecular mechanisms of associative learning and memory may regulate relapse in alcohol addiction.

Corneal Collagen Crosslinking for Post-LASIK Ectasia: An Australian Study.

PURPOSE: Post laser-assisted in situ keratomileusis (LASIK) ectasia is a rare and unpredictable complication after LASIK. Corneal collagen crosslinking (CXL) has emerged as a promising technique to address this complication. Our study evaluates the long-term efficacy of CXL for post-LASIK ectasia in an Australian setting. DESIGN: Retrospective review of post-LASIK ectasia patients referred to and treated at 3 corneal refractive surgery institutions in Sydney, Australia. METHODS: Eleven patients (14 eyes; mean age, 39.7 ± 12.6 years) underwent epithelium-off CXL with follow-up ranging from 12-78 months. Best spectacle-corrected visual acuity (BSCVA), simulated keratometry, corneal topography indices, and higher-order aberrations (HOAs) [mean ± standard error of the mean (SEM)] were measured with a rotating Scheimpflug camera (Pentacam, Oculus). Comparisons between baseline measurements and postoperative outcomes were performed using paired t test analysis. RESULTS: At last follow-up, BSCVA improved significantly by 0.2 ± 0.06 logMAR (P = 0.01), and 12 of 14 eyes showed no keratometric deterioration. Of the corneal topography indices, index of height asymmetry showed a trend toward a significant improvement (P = 0.05). There was no progression of corneal HOAs. Central corneal thickness was not significantly altered (P = 0.6). No major postoperative complications were observed. CONCLUSIONS: In the Australian setting, CXL has proven effective at stabilizing the progression of post-LASIK ectasia, inducing corneal regularity, and improving visual acuity.

Analysis of the learning curve for pre-cut corneal specimens in preparation for lamellar transplantation: a prospective, single-centre, consecutive case series prepared at the Lions New South Wales Eye Bank.

IMPORTANCE: This study is the first paper to establish a learning curve by a single technician. BACKGROUND: Preparation of pre-cut corneal endothelial grafts commenced at Lions New South Wales Eye Bank in December 2014. The primary objective of this study was to review the safety and reliability of the preparation method during the first year of production. DESIGN: This is a hospital-based, prospective case series. PARTICIPANTS: There were 234 consecutive donor corneal lenticules. METHODS: Donor lenticules were prepared by a single operator using a linear cutting microkeratome. Immediately prior to cutting, central corneal thickness values were recorded. Measurements of the corneal bed were taken immediately following lenticule preparation. Outcomes were separated by blade sizes, and intended thickness was compared to actual thickness for each setting. Early specimens were compared to later ones to assess for a learning curve within the technique. MAIN OUTCOME MEASURE: The main parameter measured is the mean difference from intended lamellar cut thickness. RESULTS: The mean final cut thickness was 122.36 ± 20.35 µm, and the mean difference from intended cut was 30.17 ± 37.45 µm. No significant difference was found between results achieved with early specimens versus those achieved with later specimens (P = 0.425). CONCLUSIONS AND RELEVANCE: Thin, reproducible endothelial grafts can routinely be produced by trained technicians at their respective eye banks without significant concerns for an extended learning curve. This service can reduce perioperative surgical complexity, required surgical paraphernalia and theatre times. The consistent preparation of single-pass, ultrathin pre-cut corneas may have additional advantages for surgeons seeking to introduce lamellar techniques.

The use of donor scleral patch in ophthalmic surgery.

Scleral tissue has been in use in ophthalmology for many years although indications for use have varied. We retrospectively reviewed scleral transplant tissue requests over a 12 month period at a local eye bank and confirmed a small but significant demand for the use of scleral tissue. Iatrogenic surgical complications are the primary indication for use. Our understanding of the indications and outcomes of scleral graft procedures is derived from case reports and small cohort series. We reviewed the current literature on existing indications for its use and discuss the relative outcomes. To our knowledge this represents the first review of scleral transplant indications and further summarises usage rates in the Lions NSW Eye Bank which may provide practical information for those surgeons who use scleral tissue and Eye Banks who supply it.

Assessment of corneal curvature using verion optical imaging system: a comparative study.

BACKGROUND: Keratometry is a critical determinant of the postoperative refractive outcome. This study evaluates the comparability of keratometry measurements obtained using the Verion Optical Imaging System with devices used in current clinical practice. Further, it determines the interobserver reliability of the Verion Optical Imaging System. DESIGN: Retrospective analysis of patient data PARTICIPANTS: Keratometric data was obtained from 100 patients presenting for pre-operative evaluation. Furthermore, repeatability and reproducibility were assessed using 15 healthy volunteers. METHODS: Corneal curvature values acquired by the Verion Optical Imaging System were compared with existing keratometry devices including autokeratometry, partial coherence interferometry (IOLMaster) and Scheimpflug corneal topography (Pentacam). MAIN OUTCOME MEASURES: Direct comparison of corneal power, cylinder, axis of astigmatism and vector analysis were performed using correlation and Bland-Altman analyses. Reproducibility and reliability of the device were assessed using within-subject standard deviation and intraclass correlation coefficients for experienced and inexperienced technicians. RESULTS: There was no statistically significant difference between Verion values and those obtained by other methods in relation to mean keratometry, corneal astigmatism, steep meridian and vector analyses (P > 0.05). Bland-Altman plots showed narrow limits of agreement for keratometry and astigmatism and wider agreement for steep meridian. Intraoperator reliability for both experienced and inexperienced operators and interoperator reproducibility showed no statistically significant differences between values. CONCLUSION: Measurements show no significant difference from those obtained by the other devices. This suggests the Verion system is en par with instruments used in current clinical practice. The Verion Optical Imaging System produces repeatable data with no difference related to operator experience.

Depression, Anxiety, and Quality of Life In Children and Adolescents With Sickle Cell Disease.

The relationships among depression, anxiety, and quality of life were tested, as were the effects of age, gender, and pain frequency on these variables in children (n = 44) and adolescents (n = 31) with sickle cell disease. Participants completed the Revised Child Anxiety and Depression Scale (ROADS) and the Pediatric Quality of Life (PedQL Generic Model). The mean and standard deviation for summary RCADS scores for the majority of participants were below the clinical thresholds of T < 65, indicating low risk for depression (n = 65; 89.3%) and anxiety (n = 70; 93.3%). The subscale scores for the different dimensions of QOL health were a) psychosocial (73.3 ± 15.9), b) emotional (75.0 ± 20.7), c) social (80.8 ± 19.1), d) school functioning (64.0 ≥ 19.8), and e) physical (77.4 ± 17.4). Significant negative correlations were found between mean total quality of life scores and symptoms of a) general anxiety (r = -0.51, p < 0.0001), b) depression (r = -0.66, p < 0.0001), c) obsessive compulsive (r = -0.53, p < 0.0001), d) panic (r = -0.60, p < 0.0001), and e) social phobia (r = -0.57, p < 0.0001). Age and gender did not have significant effects on risk for depression and anxiety or poor QOL. Pain frequency also did not have significant effects on the risk for depression and anxiety. Findings suggest that health care providers need to screen for anxiety and depression, and make referrals for early interventions to improve quality of life and promote school function in youth with sickle cell disease.

Implementation of Organ Culture storage of donor corneas: a 3 year study of its impact on the corneal transplant wait list at the Lions New South Wales Eye Bank.

Organ Culture corneal storage offers an extended storage time and increased donor pool and tissue assessment opportunities. In September 2011, the Lions New South Wales Eye Bank (LNSWEB) moved from hypothermic storage to Organ Culture corneal storage. This study evaluates the impact of implementation of Organ Culture on donor eye retrieval and the corneal transplant waiting list over a 3 year period in NSW, Australia. Retrospective review of the LNSWEB data from September 2011 to August 2014. Tissue collection, waiting list and tissue utilization data were recorded. The data from September 2008 to August 2011 for Optisol-GS storage was used for comparison. The annual donor and cornea collection rate increased 35 % and 44 % respectively with Organ Culture compared to Optisol-GS storage. The utilization rate of corneal tissue increased from 73.4 % with hypothermic storage to 77.2 % with Organ Culture storage. The transplant wait list decreased by 77.3 % from September 2011 to August 2014 and correlated with the increased rate of corneal transplantation (r = -0.9381, p < 0.0001). No other factors impacting the wait list changed over this period. Corneas not used from either storage method were due to unacceptable endothelial cell density/viability. The contamination rate of corneas stored in Organ Culture medium was low at 1.74 %. The Organ Culture storage method increases the corneal donor pool available to Eye banks. The practical benefits of the extended storage time and increased donor assessment opportunities have directly led to an increase in corneal utilization rate and a significant decrease in recipient wait list time.

Intraocular lens power calculation following laser refractive surgery.

Refractive outcomes following cataract surgery in patients that have previously undergone laser refractive surgery have traditionally been underwhelming. This is related to several key issues including the preoperative assessment (keratometry) and intraocular lens power calculations. Peer-reviewed literature is overwhelmed by the influx of methodology to manipulate the corneal or intraocular lens (IOL) powers following refractive surgery. This would suggest that the optimal derivative formula has yet been introduced. This review discusses the problems facing surgeons approaching IOL calculations in these post-refractive laser patients, the existing formulae and programs to address these concerns. Prior published outcomes will be reviewed.

Therapeutic treatment of keratoconus: a survey of local optometric practice criteria.

BACKGROUND: Defining the threshold for therapeutic and surgical intervention in patients with keratoconus presents a considerable challenge given the lack of clear, evidence-based data. Little is known about the patterns of practice and referral criteria of optometrists within Australia. METHODS: All members of the NSW branch of Optometrist Association Australia were invited to complete an online survey in January 2013. This survey was designed to elicit practice information regarding the evaluation and therapeutic treatment of patients with keratoconus in the optometric setting. RESULTS: Responses were received from 71 optometrists, of whom 65.2 per cent had 15 years or greater experience as an optometrist. Many (35.4 per cent) responded that they prescribed soft contact lenses daily. This percentage dropped to 9.2 per cent for rigid gas-permeable lenses (RGP), although 47.7 per cent said they would prescribe RGP lenses at least once per month. The main barriers to prescribing were experience with fitting RGP lenses, time and low market demand. In terms of patient referral to an ophthalmologist, the results were variable, with 34.4 per cent stating that they would refer on progression of corneal signs, 23.4 per cent suggesting no set time and 7.8 per cent would refer on initial diagnosis. Many optometrists (62.9 per cent) would refer a patient for possible surgery, when visual acuity dropped to between 6/9 and 6/12. The size or location of the practice was not associated with the number of newly diagnosed cases of keratoconus. Optometrists with greater experience were more likely to prescribe RGP lenses and co-manage patients with ophthalmologists. Ownership of a corneal topographic unit suggested an increased likelihood of prescribing RGP lenses but did not appear to alter referral patterns. CONCLUSION: Optometrists have an integral role in the diagnosis and management of patients with keratoconus. Our survey provides a basic snapshot of current, local practice. Additionally, ophthalmology should continue to work with optometry to develop guidelines for referral and co-management to optimise future outcomes for our patients.

Sensory and Thermal Quantitative Testing in Children With Sickle Cell Disease.

Very little is known about pain processing in sickle cell disease (SCD). We examined the mechanical and thermal sensory patterns in children with SCD. Children ages 10 to 17 years (n = 48; mean 13.7 ± 2.0 y; 22 females) participated in quantitative sensory testing (QST) procedures and completed a quality of life (PedsQL) and anxiety and depression scale (RCADS). Thirteen children showed evidence of abnormal pain processing, indicated by decreased sensitivity to heat or cold sensations (hypoesthesia), and pain experienced with nonpainful stimuli (allodynia). Pain ratings associated with cold and warm sensations were significantly higher in the subgroup with abnormal QST compared with the 35 SCD children with normal QST (P = 0.01 and P < 0.0001, respectively). The presence of hypoesthesia and allodynia in children with SCD may represent abnormal changes in the peripheral and central nervous system. Clinicians need to be aware that sickle cell pain may not only be inflammatory or ischemic secondary to vasoocclusion and hypoxia, but may also be neuropathic secondary to nerve injury or nerve dysfunction. Neuropathic pain in SCD may be the result of tissue damage after vaso-occlusion in neural tissues, whether peripherally or centrally. Future studies are needed to determine the presence of neuropathic pain in children with SCD.

Femtosecond laser cataract surgery: challenging cases.

PURPOSE OF REVIEW: Emerging data in the peer-reviewed literature indicate that femtosecond laser-assisted cataract surgery (LCS) is a well tolerated and effective alternative to conventional phacoemulsification. Initial reports have largely been based on findings from an optimal patient selection. As confidence with the technology has grown, clinical indications have expanded and the benefit of LCS in high-risk patients with complex cataracts is increasingly being considered. RECENT FINDINGS: We discuss challenging cataract surgery cases, citing the currently available literature alongside experience from over 3000 completed LCS cases at our centre. SUMMARY: Current experience is limited. However, LCS platforms are continuously evolving and improving. The results collected to date would suggest that the precision and safety offered by LCS may improve outcomes in these challenging cases.