Evaluating the long-term biological stability of cytokine biomarkers in ocular fluid samples.

PURPOSE: The quality of biological fluid samples is vital for optimal preanalytical procedures and a requirement for effective translational biomarker research. This study aims to determine the effects of storage duration and freeze-thawing on the levels of various cytokines in the human aqueous humour and vitreous samples. METHODS AND ANALYSIS: Human ocular aqueous humour and vitreous samples were obtained from 25 eyes and stored at -80°C for analysis. All samples were assayed for 27 cytokine biomarker concentrations (pg/mL) using a multiplex assay. Four sample storage durations following sample collection were evaluated (1 week, 3 months, 9 months and 15 months). Additionally, samples underwent up to three freeze-thaw cycles within the study period. RESULTS: Among the 27 cytokine biomarkers, concentrations of four cytokines (Interleukin (IL)-2, IL-10, IL-12 and platelet-derived growth factor-BB) were significantly decreased by storage duration at all time points, as early as 3 months following sample collection (range of 9%-37% decline between 1 week and 15 months, p<0.001). Freeze-thawing of up to three cycles did not significantly impact the cytokine biomarker concentrations in aqueous humour or vitreous. Separability of patient-specific cytokine biomarker profiles in the principal component analysis remained relatively the same over the 15 months of storage duration. CONCLUSION: The findings from this study suggest that several intraocular cytokine biomarkers in human aqueous humour and vitreous samples may be susceptible to degradation with long-term storage, as early as 3 months after collection. The overall patient-specific cytokine biomarker profiles are more stable than concentrations of individual cytokines. Future studies should focus on developing guidelines for optimal and standardised sample handling methods to ensure correct research findings about intraocular biomarkers are translated into clinical practice.

Prospective evaluation of medical student accuracy conducting direct ophthalmoscopy with an unmodified iPhone X.

PURPOSE: To evaluate fundus examination accuracy of medical students when using an unmodified iPhone X or a direct ophthalmoscope in comparison to a staff ophthalmologist's retinal examination. METHODS: In this prospective comparative analysis, patients underwent dilated fundus examination by novice medical trainees using either an unmodified iPhone X or standard direct ophthalmoscope. The primary outcome was the mean difference and degree of agreement in cup-to-disc ratio between student examination and the staff ophthalmologist's cup-to-disc observation. RESULTS: A total of 18 medical students conducted 230 retinal examinations, 117 with the iPhone X and 113 with the direct ophthalmoscope. A greater proportion of students were unable to report cup-to-disc ratio using the iPhone X (81.2%) vs direct ophthalmoscope (30.1%). Student examination of cup-to-disc ratio led to a systematic bias (95% limits of agreement) of + 0.16 (-0.22 to + 0.54) and + 0.10 (-0.36 to + 0.56) with the iPhone X and direct ophthalmoscope, respectively. iPhone X and direct ophthalmoscope student observation concordance for optic disc colour (88.7 and 82.4%, respectively) and contour (68.3 and 74.2%, respectively) demonstrated low agreement with staff ophthalmologist findings. Student iPhone X observations demonstrated lower agreement with staff findings compared to direct ophthalmoscope observations for spontaneous venous pulsations (Cohen's Kappa = -0.044 vs 0.099). CONCLUSION: Amongst medical trainees, optic disc visualization using an unmodified iPhone X was inferior to the direct ophthalmoscope. When able to visualize the optic nerve head, there was no significant difference in reported cup-to-disc ratio between modalities. However, both modalities demonstrated poor reliability in comparison to staff ophthalmologist findings.

Orbital myositis in systemic lupus erythematosus: A case report and literature review.

Orbital myositis is a rare manifestation of systemic lupus erythematosus (SLE). Herein, we report a case of orbital myositis in a patient with SLE, along with a literature review. A 45-year-old female patient presented with pain in the right eye, chemosis, proptosis, and limited abduction. Computed tomography of her orbits revealed thickening of her right lateral rectus muscle. She had no other systemic symptoms. There was no elevation in the biomarkers of inflammation or disease activity. She was treated with high-dose steroids, and her symptoms resolved rapidly. It is important to maintain a high index of suspicion for orbital myositis in patients with SLE even when there are no systemic disease activities, such that early treatment can be initiated. It is also important to rule out other mimickers such as orbital cellulitis and thyroid eye disease.

Comparison of the Ahmed and Baerveldt glaucoma shunts with combined cataract extraction.

OBJECTIVE: To compare the surgical outcomes of combined phacoemulsification with either Ahmed glaucoma valve (AGV) or Baerveldt glaucoma implant (BGI). DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 104 eyes that underwent combined phacoemulsification with either AGV (PhacoAGV; n = 57) or BGI (PhacoBGI; n = 47) implantation. METHODS: Failure was defined as uncontrolled intraocular pressure (IOP; <5 mm Hg, ≥18 mm Hg, or <20% reduction), additional glaucoma surgery, vision-threatening complications, or progression to no-light-perception vision. RESULTS: The PhacoAGV group was older (p = 0.03), had poorer baseline visual acuity (VA; p = 0.001), and had fewer previous glaucoma surgeries (p = 0.04). Both groups had similar baseline IOP (PhacoAGV: 26.4 ± 8.3 mm Hg; PhacoBGI: 25.7 ± 7.3; p = 0.66) and glaucoma medications (PhacoAGV: 3.8 ± 1.0; PhacoBGI: 3.6 ± 1.5; p = 0.54). At 2 years, failure rates were 44% in the PhacoAGV group and 23% in the PhacoBGI group (p = 0.02). Both groups had similar mean IOP reduction (PhacoAGV: 45%; PhacoBGI: 47%, p = 0.67) and medication use reduction (PhacoAGV: 47%; PhacoBGI: 58%, p = 0.38). The PhacoBGI group had higher IOP and medication use up to 1 month (p < 0.05). Both groups improved in VA from baseline (p < 0.05) and had similar overall complication rates (p = 0.31). The PhacoBGI group required more overall interventions (p < 0.0005). CONCLUSIONS: This comparative study found no difference in IOP, glaucoma medications, or complication rates between PhacoAGV and PhacoBGI at 2 years, despite BGIs being implanted in patients at higher risk for failure. The PhacoAGV group had higher failure rates at 2 years. Both groups had significant improvements in VA due to removal of their cataracts. The PhacoBGI group required more interventions, but most of these were minor slit-lamp procedures.

Teaching binocular indirect ophthalmoscopy to novice residents using an augmented reality simulator.

OBJECTIVE: To compare the traditional teaching approach of binocular indirect ophthalmoscopy (BIO) to the EyeSI augmented reality (AR) BIO simulator. DESIGN: Prospective randomized control trial. PARTICIPANTS: 28 post-graduate year one (PGY1) ophthalmology residents. METHODS: Residents were recruited at the 2012 Toronto Ophthalmology Residents Introductory Course (TORIC). 15 were randomized to conventional teaching (Group 1), and 13 to augmented reality simulator training (Group 2). 3 vitreoretinal fellows were enrolled to serve as experts. Evaluations were completed on the simulator, with 3 tasks, and outcome measures were total raw score, total time elapsed, and performance. RESULTS: Following conventional training, Group 1 residents were outperformed by vitreoretinal fellows with respect to all 3 outcome measures. Following AR training, Group 2 residents demonstrated superior total scores and performance compared to Group 1 residents. Once the Group 1 residents also completed the AR BIO training, there was a significant improvement compared to their baseline scores, and were now on par with Group 2 residents. CONCLUSIONS: This study provides construct validity for the EyeSI AR BIO simulator and demonstrates that it may be superior to conventional BIO teaching for novice ophthalmology residents.

Proportion of undetected narrow angles or angle closure in cataract surgery referrals.

OBJECTIVE: To determine the proportion of patients referred for cataract surgery consultation who had undetected narrow angles (primary angle closure suspect [PACS], primary angle closure [PAC], or primary angle closure glaucoma [PACG]). DESIGN: Retrospective chart review. PARTICIPANTS: Phakic patients referred by eye care providers (optometrists and ophthalmologists) to a tertiary centre for cataract management between July 1, 2010 and June 30, 2012 were identified and reviewed. METHODS: Demographic, referral, and specialist assessment information, as well as biometric data, including anterior segment optical coherence tomography, were collected. Patients with undetected narrow angles were identified. Univariate tests and multivariable analyses were performed to determine risk factors for narrow angles or angle closure. RESULTS: A total of 1229 patients were included. The mean patient age was 67.8 ± 13.0 years, 53.9% of patients were female, and 26.8% were Asian or South Asian. Of the sample population, 139 (11.3%) patients had PACS, 7 (0.6%) had PAC, and 12 (1.0%) had PACG. Overall, 158 (12.9%) patients had narrow angles or angle closure. Multivariable logistic regression using generalized estimating equations confirmed 3 independent predictors of PACS/angle closure: Asian race (odds ratio 2.82, p < 0.001), shorter axial length (AL) (odds ratio 1.25, p = 0.03), and smaller anterior chamber depth (ACD; odds ratio 33.3, p < 0.001). A patient of Asian race referred for cataract surgery with ACD <2.8 mm and AL <23 mm had a 52% probability of having PACS/angle closure (range 42%-62%) versus 3% if these 3 factors were not present. CONCLUSIONS: Of patients referred for cataract surgery, 1.5% were found to have undetected narrow angles or angle closure, implying that gonioscopy may not be adequately performed in this patient population.

Undetected angle closure in patients with a diagnosis of open-angle glaucoma.

OBJECTIVE: The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma centre with a diagnosis of open-angle glaucoma (OAG) who were found to have angle closure glaucoma. DESIGN: Retrospective chart review. METHODS: Consecutive new patients referred for glaucoma management to a tertiary centre between July 2010 and December 2011 were reviewed. Patients whose referrals for glaucoma assessment specified angle status as "open" were included. The data collected included glaucoma specialist's angle assessment, diagnosis, and glaucoma severity. The status of those with 180 degrees or more Shaffer angle grading of 0 was classified as "closed." RESULTS: From 1234 glaucoma referrals, 179 cases were specified to have a diagnosis of OAG or when angles were known to be open. Of these, 16 (8.9%) were found on examination by the glaucoma specialist to have angle closure. Pseudoexfoliation was present in 4 of 16 patients (25%) in the missed angle-closure glaucoma (ACG) group and 22 of 108 patients (13.5%) in the remaining OAG group. There was no difference found in demographic or ocular biometric parameters between those with confirmed OAG versus those with missed ACG. CONCLUSIONS: Almost 1 in 11 patients referred by ophthalmologists to a tertiary glaucoma centre with a diagnosis of OAG were in fact found to have angle closure. Given the different treatment approaches for ACG versus OAG, this study suggests a need to strengthen angle evaluations.

Suture fixation of iris-claw intraocular lens.

UNLABELLED: We report a technique to surgically manage the damaged haptic of an iris-claw intraocular lens (IOL). An 89-year-old woman initially presented with a subluxated posterior chamber IOL that was exchanged for an Artisan iris-claw IOL. The IOL had been enclavated nasally and temporally, but it deenclavated nasally 4 weeks postoperatively. During surgery to reposition the IOL, 1 haptic of the nasal claw was seen to be damaged. It was sutured to the iris with 10-0 polypropylene using a CIF-4 needle. The postoperative outcome was good. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Needs assessment of ophthalmology education for primary care physicians in training: comparison with the International Council of Ophthalmology recommendations.

BACKGROUND: This cross-sectional survey assessed the adequacy of ophthalmology teaching in undergraduate medical education and evaluated the comfort level of family medicine residents in diagnosing and managing common ophthalmic conditions. METHODS: Postgraduate year 1 and 2 family medicine residents at the University of Western Ontario were recruited for this study. The main outcome measures were hours of classroom and clinic-based instruction on ophthalmology during undergraduate medical education, and the comfort level in ophthalmic clinical skills and managing various ophthalmic conditions. RESULTS: In total, 54 (33.3%) of 162 family medicine residents responded to the survey. Residents reported an average of 27.1 ± 35.1 hours and 39.8 ± 47.1 hours of classroom and clinical ophthalmology instruction, respectively. However, most residents (80%) responded as feeling only "somewhat comfortable" or "not at all comfortable" in assessing and managing common ophthalmic conditions, including ocular emergencies, such as acute angle closure glaucoma and ocular chemical burn. A positive correlation was seen between overall comfort level and hours of classroom instruction (P < 0.05). CONCLUSION: The number of hours of ophthalmology training received by family medicine residents during medical school meets the International Council of Ophthalmology Task Force recommendations. However, family medicine residents appear to be uncomfortable in handling treatable but potentially sight-threatening ocular conditions. Standardizing the undergraduate medical education ophthalmology curriculum and increasing hours of ophthalmology training during postgraduate family medicine residency may be useful in bridging this gap in knowledge.