Keratoconus:a review

Keratoconus is the most common primary ectasia. It usually occurs in the second decade of life and affects both genders and all ethnicities. The estimated prevalence in the general population is 54 per 100,000. Ocular signs and symptoms vary depending on disease severity. Early forms normally go unnoticed unless corneal topography is performed. Disease progression is manifested with a loss of visual acuity which cannot be compensated for with spectacles. Corneal thinning frequently precedes ectasia. In moderate and advance cases, a hemosiderin arc or circle line, known as Fleischer's ring, is frequently seen around the cone base. Vogt's striaes, which are fine vertical lines produced by Descemet's membrane compression, is another characteristic sign. Most patients eventually develop corneal scarring. Munson's sign, a V-shape deformation of the lower eyelid in downward position; Rizzuti's sign, a bright reflection from the nasal area of the limbus when light is directed to the limbus temporal area; and breakages in Descemet's membrane causing acute stromal oedema, known as hydrops, are observed in advanced stages. Classifications based on morphology, disease evolution, ocular signs and index-based systems of keratoconus have been proposed. Theories into the genetic, biomechanical and biochemical causes of keratoconus have been suggested. Management varies depending on disease severity. Incipient cases are managed with spectacles, mild to moderate cases with contact lenses and severe cases can be treated with keratoplasty. This article provides a review on the definition, epidemiology, clinical features, classification, histopathology, aetiology and pathogenesis, and management and treatment strategies for keratoconus.

Ophthalmic engineering:the development of novel instrumentation to further research in the field

The principle theme of this thesis is the advancement and expansion of ophthalmic research via the collaboration between professional Engineers and professional Optometrists. The aim has been to develop new and novel approaches and solutions to contemporary problems in the field. The work is sub divided into three areas of investigation; 1) High technology systems, 2) Modification of current systems to increase functionality, and 3) Development of smaller more portable and cost effective systems. High Technology Systems: A novel high speed Optical Coherence Tomography (OCT) system with integrated simultaneous high speed photography was developed achieving better operational speed than is currently available commercially. The mechanical design of the system featured a novel 8 axis alignment system. A full set of capture, analysis, and post processing software was developed providing custom analysis systems for ophthalmic OCT imaging, expanding the current capabilities of the technology. A large clinical trial was undertaken to test the dynamics of contact lens edge interaction with the cornea in-vivo. The interaction between lens edge design, lens base curvature, post insertion times and edge positions was investigated. A novel method for correction of optical distortion when assessing lens indentation was also demonstrated. Modification of Current Systems: A commercial autorefractor, the WAM-5500, was modified with the addition of extra hardware and a custom software and firmware solution to produce a system that was capable of measuring dynamic accommodative response to various stimuli in real time. A novel software package to control the data capture process was developed allowing real time monitoring of data by the practitioner, adding considerable functionality of the instrument further to the standard system. The device was used to assess the accommodative response differences between subjects who had worn UV blocking contact lens for 5 years, verses a control group that had not worn UV blocking lenses. While the standard static measurement of accommodation showed no differences between the two groups, it was determined that the UV blocking group did show better accommodative rise and fall times (faster), thus demonstrating the benefits of the modification of this commercially available instrumentation. Portable and Cost effective Systems: A new instrument was developed to expand the capability of the now defunct Keeler Tearscope. A device was developed that provided a similar capability in allowing observation of the reflected mires from the tear film surface, but with the added advantage of being able to record the observations. The device was tested comparatively with the tearscope and other tear film break-up techniques, demonstrating its potential. In Conclusion: This work has successfully demonstrated the advantages of interdisciplinary research between engineering and ophthalmic research has provided new and novel instrumented solutions as well as having added to the sum of scientific understanding in the ophthalmic field.

A decade of silicone hydrogel development:surface properties, mechanical properties, and ocular compatibility

Since the initial launch of silicone hydrogel lenses, there has been a considerable broadening in the range of available commercial material properties. The very mobile silicon–oxygen bonds convey distinctive surface and mechanical properties on silicone hydrogels, in which advantages of enhanced oxygen permeability, reduced protein deposition, and modest frictional interaction are balanced by increased lipid and elastic response. There are now some 15 silicone hydrogel material variants available to practitioners; arguably, the changes that have taken place have been strongly influenced by feedback based on clinical experience. Water content is one of the most influential properties, and the decade has seen a progressive rise from lotrafilcon-A (24%) to efrofilcon-A (74%). Moduli have decreased over the same period from 1.4 to 0.3 MPa, but not solely as a result of changes in water content. Surface properties do not correlate directly with water content, and ingenious approaches have been used to achieve desirable improvements (e.g., greater lubricity and lower contact angle hysteresis). This is demonstrated by comparing the hysteresis value of the earliest (lotrafilcon-A, >40°) and most recent (delefilcon-A, <10°) coated silicone hydrogels. Although wettability is important, it is not of itself a good predictor of ocular response because this involves a much wider range of physicochemical and biochemical factors. The interference of the lens with ocular dynamics is complex leading separately to tissue–material interactions involving anterior and posterior lens surfaces. The biochemical consequences of these interactions may hold the key to a greater understanding of ocular incompatibility and end of day discomfort.

Factors affecting corneoscleral topography

PURPOSE: To evaluate factors affecting corneoscleral profile (CSP) using Anterior Segment Optical Coherence Tomography (AS-OCT) in combination with conventional videokeratoscopy. METHODS: OCT data were collected from 204 subjects of mean age 34.9 years (SD: ±15.2 yrs, range 18 to 65) using the Zeiss Visante AS-OCT and Medmont M300 corneal topographer. Measurements of corneal diameter (CD), corneal sagittal height (CS), iris diameter (ID), corneoscleral junction angle (CSJ) and scleral radius (SR) were extracted from multiple OCT images. Horizontal visible iris diameter (HVID) and vertical palpebral aperture (PA) were measured using a slit lamp graticule. Subject body height was also measured. Associations were then sought between CSP variables and age, height, ethnicity, sex and refractive error data collected. Results: Significant correlations were found between age and ocular topography variables of HVID, PA, CSJ, SR and ID (P<0.0001), while height correlated with HVID, CD and ID, and power vector terms only with vertical plane keratometry, CD and CS. Significant differences were noted between ethnicities with respect to CD (P=0.0046), horizontal and vertical CS (P=0.0068 and P=0.0095), and also horizontal ID (P=0.0010), while the same variables, with the exception of vertical CS, also varied with sex; horizontal CD (P=0.0018), horizontal CS (P=0.0018) and ID (P=0.0012). Age accounted for up to 36% of the variance in CSP variables. Conclusion: Age is the main factor influencing corneoscleral topography; consequently, this should be taken into consideration in contact lens design, in the optimization of surgical procedures involving the cornea and sclera and in IOL selection.

A preliminary investigation into the effects of ocular lubricants on higher order aberrations in normal and dry eye subjects

Purpose: To study the effects of ocular lubricants on higher order aberrations in normal and self-diagnosed dry eyes. Methods: Unpreserved hypromellose drops, Tears Again™ liposome spray and a combination of both were administered to the right eye of 24 normal and 24 dry eye subjects following classification according to a 5 point questionnaire. Total ocular higher order aberrations, coma, spherical aberration and Strehl ratios for higher order aberrations were measured using the Nidek OPD-Scan III (Nidek Technologies, Gamagori, Japan) at baseline, immediately after application and after 60. min. The aberration data were analyzed over a 5. mm natural pupil using Zernike polynomials. Each intervention was assessed on a separate day and comfort levels were recorded before and after application. Corneal staining was assessed and product preference recorded after the final measurement for each intervention. Results: Hypromellose drops caused an increase in total higher order aberrations (p= <0.01 in normal and dry eyes) and a reduction in Strehl ratio (normal eyes: p= <0.01, dry eyes p= 0.01) immediately after instillation. There were no significant differences between normal and self-diagnosed dry eyes for response to intervention and no improvement in visual quality or reduction in higher order aberrations after 60. min. Differences in comfort levels failed to reach statistical significance. Conclusion: Combining treatments does not offer any benefit over individual treatments in self-diagnosed dry eyes and no individual intervention reached statistical significance. Symptomatic subjects with dry eye and no corneal staining reported an improvement in comfort after using lubricants. © 2013 British Contact Lens Association.

Editorial

Readers may have noted that a short but very important announcement was made in the last issue of CLAE, at the top of the contents page. CLAE has been accepted by Thomson Reuters for abstracting and indexing in its SciSearch, Journal Citation Reports, and Current Contents services. This will ensure a greater visibility to the international research community. In addition, in June 2012 CLAE will receive its very first official Impact Factor – a measure of journal influence of importance to authors and readers alike. The impact factor value has not yet been decided but internal estimates by Elsevier estimate it will be around 1, and it will be applied to all CLAE issue back to January 2009 (volume 32). I would guess readers at this stage would have one of two responses – either ‘that's good news’ or perhaps ‘what's an impact factor?’ If you are in the latter camp then allow me to try and explain. Basically the impact factor or citation index of a journal is based on how many times in the previous year papers published in that journal in the previous two years were cited by authors publishing in other journals. So the 2012 impact factor for CLAE is calculated on how many times in 2011 papers that were published in CLAE in 2010 and 2009 were cited in other journals in 2011, divided by the number of papers published in CLAE 2010 and 2009. Essentially authors will try and get their work published in journals with a higher impact factor as it is thought that the paper will be cited more by other authors or the paper will have higher visibility in the arena. For universities having its published output in higher journals is one of the markers used to judge esteem. For individual authors publishing in journals with a higher impact factor or the number of times one of their papers is published is something that they are likely to add to their CVs or demonstrate the importance of their work. Journals with higher impact factors tend to be more review journals or journals with a wider spectrum so for a relatively small journal with a specialised field like CLAE it is great to be listed with a citation index. The awarding of a citation index crowns many changes that CLAE has undergone since the current Editor took the reins in 2005. CLAE has increased from four issues (in 2004) to six issues per year with at least one review article per issue and one article with continuing education per issue. The rejection rate has gone up significantly meaning that only best papers are published (currently it stands at 37%). CLAE has been Medline/Pubmed indexed for a few years now which is also a very important factor in improving visibility of the journal. The submission and reviewing process for CLAE in now entirely online and finally the editorial board has changed from being merely a list of keynote people to being an active group of keynote people who are enthusiastically involved with the journal. From the editorial board one person is appointed as a Reviews Editor plus we have two additional editors who work as Regional Editors. As ever, on behalf of CLAE I would like to thank the BCLA Council for their continued support (especially Vivien Freeman) and Elsevier for their continuing guidance (in particular Andrew Miller and Rosie Davey) and the excellent Editorial Board (Christopher Snyder, Pauline Cho, Eric Papas, Jan Bergmanson, Roger Buckley, Patrick Caroline, Dwight Cavanagh, Robin Chalmers, Michael Doughty, Nathan Efron, Michel Guillon, Nizar Hirji, Meng Lin, Florence Malet, Philip Morgan, Deborah Sweeney, Brian Tighe, Eef van Der Worp, Barry Weissman, Mark Willcox, James Wolffsohn and Craig Woods). And finally, a big thanks to the authors and reviewers who work tirelessly putting manuscripts together for publication in CLAE. Copyright © 2012 Published by Elsevier Ltd.

EUROMCONTACT

Editorial

Short-term changes in ocular biometry and refraction after discontinuation of long-term orthokeratology

OBJECTIVE: To assess refractive and biometric changes 1 week after discontinuation of lens wear in subjects who had been wearing orthokeratology (OK) contact lenses for 2 years. METHODS: Twenty-nine subjects aged 6 to 12 years and with myopia of -0.75 to -4.00 diopters (D) and astigmatism of ≤1.00 D participated in the study. Measurements of axial length and anterior chamber depth (Zeiss IOLMaster), corneal power and shape, and cycloplegic refraction were taken 1 week after discontinuation and compared with those at baseline and after 24 months of lens wear. RESULTS: A hyperopic shift was found at 24 months relative to baseline in spherical equivalent refractive error (+1.86±1.01 D), followed by a myopic shift at 1 week relative to 24 months (-1.93±0.92 D) (both P<0.001). Longer axial lengths were found at 24 months and 1 week in comparison to baseline (0.47±0.18 and 0.51±0.18 mm, respectively) (both P<0.001). The increase in axial length at 1 week relative to 24 months was statistically significant (0.04±0.06 mm; P=0.006). Anterior chamber depth did not change significantly over time (P=0.31). Significant differences were found between 24 months and 1 week relative to baseline and between 1-week and 24-month visits in mean corneal power (-1.68±0.80, -0.44±0.32, and 1.23±0.70 D, respectively) (all P≤0.001). Refractive change at 1 week in comparison to 24 months strongly correlated with changes in corneal power (r=-0.88; P<0.001) but not with axial length changes (r=-0.09; P=0.66). Corneal shape changed significantly between the baseline and 1-week visits (0.15±0.10 D; P<0.001). Corneal shape changed from a prolate to a more oblate corneal shape at the 24-month and 1-week visits in comparison to baseline (both P≤0.02) but did not change significantly between 24 months and 1 week (P=0.06). CONCLUSIONS: The effects of long-term OK on ocular biometry and refraction are still present after 1-week discontinuation of lens wear. Refractive change after discontinuation of long-term OK is primarily attributed to the recovery of corneal shape and not to an increase in the axial length.

A review of non-pharmacological and pharmacological management of seasonal and perennial allergic conjunctivitis

Allergic eye disease encompasses a group of hypersensitivity disorders which primarily affect the conjunctiva and its prevalence is increasing. It is estimated to affect 8% of patients attending optometric practice but is poorly managed and rarely involves ophthalmic assessment. Seasonal allergic conjunctivitis (SAC) is the most common form of allergic eye disease (90%), followed by perennial allergic conjunctivitis (PAC; 5%). Both are type 1 IgE mediated hypersensitivity reactions where mast cells play an important role in pathophysiology. The signs and symptoms are similar but SAC occurs periodically whereas PAC occurs year round. Despite being a relatively mild condition, the effects on the quality of life can be profound and therefore they demand attention. Primary management of SAC and PAC involves avoidance strategies depending on the responsible allergen(s) to prevent the hypersensitivity reaction. Cooled tear supplements and cold compresses may help bring relief. Pharmacological agents may become necessary as it is not possible to completely avoid the allergen(s). There are a wide range of anti-allergic medications available, such as mast cell stabilisers, antihistamines and dual-action agents. Severe cases refractory to conventional treatment require anti-inflammatories, immunomodulators or immunotherapy. Additional qualifications are required to gain access to these medications, but entry-level optometrists must offer advice and supportive therapy. Based on current evidence, the efficacy of anti-allergic medications appears equivocal so prescribing should relate to patient preference, dosing and cost. More studies with standardised methodologies are necessary elicit the most effective anti-allergic medications but those with dual-actions are likely to be first line agents. © 2011 British Contact Lens Association.

Is randomisation necessary for measuring defocus curves in pre-presbyopes?

Purpose: Defocus curves are used to evaluate the subjective range of clear vision of presbyopic corrections such as in eyes implanted with accommodating intraocular lenses (IOLs). This study determines whether letter sequences and/or lens presentation order ought to be randomised when measuring defocus curves. Methods: Defocus curves (range +2.00DS to -2.00DS) were measured on 18 pre-presbyopic subjects (mean age 24.1 ± 4.2 years) for six combinations of sequential or randomised positive or negative lens progression and non-randomised or randomised letter sequences. The letters were presented on a computerised logMAR chart at 6 m. Results: Overall there was a statistically significant difference between the six combinations (ANOVA, p < 0.05) attributable to the combination of non-randomised letters with non-randomised lens progression from negative to positive defocus (p < 0.01). There was no statistically significant difference in defocus curve measurements if both letters and lens order were randomised compared to if only one of these variables was randomised (p > 0.05). Non-randomised letters, with a sequential lens progression from negative to positive, was significantly different to all other combinations when compared individually (Student's T-test, p < 0.003 on all comparisons), and was confirmed as the sole source of the overall significant difference. There was no statistically significant difference if both lens presentation order and letter sequences were randomised compared to if only one or the other of these variables was randomised. Conclusion: Non-randomised letters and non-randomised lens progression on their own did not affect the subjective amplitude of accommodation as measured by defocus curves, although their combination should be avoided. © 2007 British Contact Lens Association.

Comparison between graticule and image capture assessment of lower tear film meniscus height

Purpose: To compare graticule and image capture assessment of the lower tear film meniscus height (TMH). Methods: Lower tear film meniscus height measures were taken in the right eyes of 55 healthy subjects at two study visits separated by 6 months. Two images of the TMH were captured in each subject with a digital camera attached to a slit-lamp biomicroscope and stored in a computer for future analysis. Using the best of two images, the TMH was quantified by manually drawing a line across the tear meniscus profile, following which the TMH was measured in pixels and converted into millimetres, where one pixel corresponded to 0.0018 mm. Additionally, graticule measures were carried out by direct observation using a calibrated graticule inserted into the same slit-lamp eyepiece. The graticule was calibrated so that actual readings, in 0.03 mm increments, could be made with a 40× ocular. Results: Smaller values of TMH were found in this study compared to previous studies. TMH, as measured with the image capture technique (0.13 ± 0.04 mm), was significantly greater (by approximately 0.01 ± 0.05 mm, p = 0.03) than that measured with the graticule technique (0.12 ± 0.05 mm). No bias was found across the range sampled. Repeatability of the TMH measurements taken at two study visits showed that graticule measures were significantly different (0.02 ± 0.05 mm, p = 0.01) and highly correlated (r = 0.52, p < 0.0001), whereas image capture measures were similar (0.01 ± 0.03 mm, p = 0.16), and also highly correlated (r = 0.56, p < 0.0001). Conclusions: Although graticule and image analysis techniques showed similar mean values for TMH, the image capture technique was more repeatable than the graticule technique and this can be attributed to the higher measurement resolution of the image capture (i.e. 0.0018 mm) compared to the graticule technique (i.e. 0.03 mm). © 2006 British Contact Lens Association.

Management of dry eye in UK pharmacies

Purpose - To investigate the ability of pharmacy staff in the United Kingdom (UK) to diagnose and treat dry eye. Methods - A mystery shopper technique to simulate a patient with presumed dry eye was used in 50 pharmacy practices in major towns and cities across the UK. Pharmacies were unaware of their involvement in the study. With the exception of a predetermined opening statement to initiate the consultation, no further information was volunteered. Questions asked, diagnoses given, management strategy advised and staff type was recorded immediately after the consultation. Results - The mean number of questions was 4.5 (SD 1.7; range 1–10). The most common question was the duration of symptoms (56%) and the least common was whether the patient had a history of headaches (2%). All pharmacy staff gave a diagnosis, but the majority were incorrect (58%), with only 42% correctly identifying dry eye. Treatment was advised by 92% of pharmacy staff, with the remaining 8% advising referral directly to the patient's GP or optometrist. Dry eye treatments involved topical ocular lubrication via eye drops (90%) and lipid based sprays (10%). However, only 10% gave administration advice, 10% gave dosage advice, 9% asked about contact lens wear, and none offered follow up although 15% also advised GP or optometrist referral. Conclusions - There is a need for improved ophthalmological training amongst pharmacists and pharmacy staff and establishment of cross referral relationships between pharmacies and optometry practices.

Ocular surface temperature:a review

Purpose. To review the evolution in ocular temperature measurement during the last century and examine the advantages and applications of the latest noncontact techniques. The characteristics and source of ocular surface temperature are also discussed. Methods. The literature was reviewed with regard to progress in human thermometry techniques, the parallel development in ocular temperature measurement, the current use of infrared imaging, and the applications of ocular thermography. Results. It is widely acknowledged that the ability to measure ocular temperature accurately will increase the understanding of ocular physiology. There is a characteristic thermal profile across the anterior eye, in which the central area appears coolest. Ocular surface temperature is affected by many factors, including inflammation. In thermometry of the human eye, contact techniques have largely been superseded by infrared imaging, providing a noninvasive and potentially more accurate method of temperature measurement. Ocular thermography requires high resolution and frame rate: features found in the latest generation of cameras. Applications have included dry eye, contact lens wear, corneal sensitivity, and refractive surgery. Conclusions. Interest in the temperature of the eye spans almost 130 years. It has been an area of research largely driven by prevailing technology. Current instrumentation offers the potential to measure ocular surface temperature with more accuracy, resolution, and speed than previously possible. The use of dynamic ocular thermography offers great opportunities for monitoring the temperature of the anterior eye. © 2005 Contact Lens Association of Ophthalmologists, Inc.

Grading of corneal transparency

Aim: To examine the academic literature on the grading of corneal transparency and to assess the potential use of objective image analysis. Method: Reference databases of academic literature were searched and relevant manuscripts reviewed. Annunziato, Efron (Millennium Edition) and Vistakon-Synoptik corneal oedema grading scale images were analysed objectively for relative intensity, edges detected, variation in intensity and maximum intensity. In addition, corneal oedema was induced in one subject using a low oxygen transmissibility (Dk/t) hydrogel contact lens worn for 3 hours under a light eye patch. Recovery from oedema was monitored over time using ultrasound pachymetry, high and low contrast visual acuity measures, bulbar hyperaemia grading and transparency image analysis of the test and control eyes. Results: Several methods for assessing corneal transparency are described in the academic literature, but none have gained widespread in clinical practice. The change in objective image analysis with printed scale grade was best described by quadratic parametric or sigmoid 3-parameter functions. ‘Pupil image scales’ (Annunziato and Vistakon-Synoptik) were best correlated to average intensity; however, the corneal section scale (Efron) was strongly correlated to variations in intensity. As expected, patching an eye wearing a low Dk/t hydrogel contact lens caused a significant (F=119.2, P<0.001) 14.3% increase in corneal thickness, which gradually recovered under open eye conditions. Corneal section image analysis was the most affected parameter and intensity variation across the slit width, in isolation, was the strongest correlate, accounting for 85.8% of the variance with time following patching, and 88.7% of the variance with corneal thickness. Conclusion: Corneal oedema is best determined objectively by the intensity variation across the width of a corneal section. This can be easily measured using a slit-lamp camera connected to a computer. Oedema due to soft contact lens wear is not easily determined over the pupil area by sclerotic scatter illumination techniques.

Microwave decontamination of eyelid warming devices for the treatment of meibomian gland dysfunction

PURPOSE: The role of bacteria in meibomian gland dysfunction is unclear, yet contamination of compresses used as treatment may exacerbate this condition. This study therefore determined the effect of heating on bacteria on two forms of compress. METHODS: Cotton flannels and MGDRx EyeBags (eyebags) were inoculated by adding experimental inoculum (Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa; one species for each set of 3 eyebags and flannels). One of each were then randomised in to 3 groups: no heating (control); therapeutic (47.4±0.7°C); or sanitisation (68±1.1°C). After treatment, bacteria cell numbers were calculated. The experiment was repeated in triplicate. RESULTS: There was a statistically significant difference between each treatment with the eyebag for S. aureus (control=7.15±0.11logC/ml, therapeutic heating=5.24±0.59logC/ml, sanitisation heating=3.48±1.43logC/ml; P<0.001) and S. pyogenes (7.36±0.13, 5.73±0.26, 4.75±0.54; P<0.001). P. aeruginosa also showed a significant reduction (P<0.001) from control (6.39±0.34) to therapeutic (0.33±0.26) and sanitisation (0.33±0.21), but the latter were similar (P=1.000). For the flannels, there was significant difference between each treatment for S. aureus (6.89±0.46, 3.96±1.76, 0.42±0.90; P<0.001). For S. pyogenes, there was a significant reduction (P<0.001) from control (7.51±0.10) to therapeutic (5.91±0.62) and sanitisation (5.18±0.8), but the latter were similar (P=0.07). For P. aeruginosa, there was a significant difference (P<0.001) from control (7.15±0.36) to sanitisation (5.83±0.44); but not to therapeutic (6.84±0.31) temperatures (P=0.07). CONCLUSIONS: Therapeutic heating produces a significant reduction in bacteria on the eyebags, but only sanitisation heating appears effective for flannels. However, patients should be advised to heat the eyebag to sanitisation temperatures on initial use.