Publications by authors named "Stephanie L Watson"

60 Publications

Item banks for measurement of refractive error-specific quality of life.

Ophthalmic Physiol Opt 2021 Mar 2. Epub 2021 Mar 2.

School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.

Purpose: To evaluate the psychometric properties of refractive error-specific quality of life (QoL) item banks and assess their performance using computerised adaptive testing (CAT) simulations.

Methods: In this cross-sectional study a 392-item questionnaire, grouped under 11 QoL domains, was interviewer-administered to 305 people with refractive error [mean age ± S.D., 30.5 ± 14.1 (range (18 to 83) years; male, 50.5%; mean ± S.D. spherical equivalent refractive error -2.4 ± 2.9 (range: -15.0 to +11.0) Dioptres; spectacles (n = 257), contact lens (n = 37), refractive surgery (n = 25), uncorrected refractive error (n = 57)]. Rasch analysis was conducted on each QoL domain using the Andrich rating scale model to investigate parameters including response category functioning, person- and item-reliability, infit and outfit statistics, unidimensionality, targeting, differential item functioning and local item dependency. The resulting item banks underwent CAT simulations in 1,000 cases with 'high' and 'moderate' precision stopping rules.

Results: Rasch analysis iterations resulted in 13 refractive error-specific item banks (Convenience, Health concerns, Economic, Activity limitation, Mobility, Emotional, Social, Visual symptoms frequency, Visual symptoms severity, Visual symptoms bothersome, Comfort symptoms frequency, Comfort symptoms severity and Comfort symptoms bothersome), containing a total of 366 items. The item banks had good psychometric properties including satisfactory measurement precision, infit and outfit statistics and unidimensionality. In CAT simulations, the mean number of items required to achieve high and moderate measurement precision was 9.4 and 4.7, respectively.

Conclusion: Overall, refractive error-specific QoL item banks show promise in their ability to comprehensively and precisely evaluate a range of quality of life parameters. These items banks when administered using a CAT system offer unique outcome tools for implementation in clinical trials, healthcare and research.
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http://dx.doi.org/10.1111/opo.12792DOI Listing
March 2021

Predisposing factors, microbiological features and outcomes of patients with clinical presumed concomitant microbial and herpes simplex keratitis.

Eye (Lond) 2021 Feb 19. Epub 2021 Feb 19.

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health, Sydney, NSW, Australia.

Background/objectives: To describe the predisposing factors, pathogens and outcomes in patients with clinical presumed concomitant microbial and herpes simplex keratitis (HSK) at Sydney Eye Hospital, Australia over a 5-year period.

Subjects/methods: A retrospective case review was conducted. Patients with clinical presumed concomitant microbial and HSK from 2012 to 2016 were identified from pathology and hospital coding databases. Data were extracted from the medical records. VA was converted to the logarithm of the minimum angle of resolution (logMAR). 'Poor' outcome was defined as final VA worse than 6/60, or decrease in VA during treatment, or presence of complication, or needed surgical intervention.

Results: 126 episodes in 121 patients were included; median age 70 years (range 18-96); 56% male. Predisposing factors included blepharitis 20/126 (16%) cases, and corneal transplantation 19 (15%). Forty-six (37%) cases had prior HSK. Coagulase-negative staphylococci 51/116 (44%), Staphylococcus aureus 11 (9%), and Pseudomonas aeruginosa 11 (9%) were the most common isolates. The median VA at initial visit was 1.7 logMAR (range 0.04-2.7) and at final visit, 0.98 logMAR (range 0-2.7) (P < 0.05). Complications occurred in 70 episodes: persistent epithelial defect in 38 (30%); intraocular pressure elevation in 15 (12%), and corneal perforation in 12 (10%). 'Poor' outcome was recorded in 46/75 (61%) episodes.

Conclusions: Patients with clinical presumed concomitant microbial and HSK face significant ocular morbidity and poor visual outcome. In our setting, previous HSK, corneal and ocular surface disease, were common predisposing factors and Gram-positive bacteria were the most commonly associated organisms.
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http://dx.doi.org/10.1038/s41433-021-01440-1DOI Listing
February 2021

Microbial Keratitis After Corneal Collagen Cross-Linking for Corneal Ectasia.

Asia Pac J Ophthalmol (Phila) 2021 Jan 29. Epub 2021 Jan 29.

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia Corneal Unit, Sydney Eye Hospital, Sydney, New South Wales, Australia.

Purpose: The aim of this study was to report the clinical profile and microbiological of patients with microbial keratitis post accelerated corneal collagen cross-linking (CXL).

Methods: A retrospective case series of all patients diagnosed with microbial keratitis post-CXL who attended the Sydney Eye Hospital, Australia from January 1, 2012 to December 31, 2019 were included. Patients were identified from hospital coding and pathology data. Data were extracted from patients' medical records.

Results: Eleven eyes from 10 patients with a mean age of 29 ± 11 years (range 16-48) were included. The median time of infection after CXL surgery was 4 days [interquartile range (IQR) 3-83]. Median initial and final Visual acuity at presentation were 1.3 logMAR (IQR 1-2.0) and 0.8 logMAR (IQR 0.6-1.2), respectively. The culture positivity rate was 92%, identifying 13 isolates, predominately made up of coagulase-negative Staphylococcus (n = 6, 50%) and Staphylococcus aureus (n = 3, 25%). The median epithelial healing time was 30 days (IQR 15-53).

Conclusions: Post-CXL microbial keratitis was predominately associated with gram-positive bacteria and in some cases delayed epithelialization. Microbial keratitis post-CXL may lead to moderate to poor patient outcomes.
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http://dx.doi.org/10.1097/APO.0000000000000379DOI Listing
January 2021

Outcomes of Patients with Herpes Simplex Keratitis Before and After the Implementation of a New Treatment Guideline in Sydney, Australia.

Asia Pac J Ophthalmol (Phila) 2021 Jan 19. Epub 2021 Jan 19.

Discipline of Ophthalmology, Faculty of Medicine and Health, Save Sight Institute, The University of Sydney, New South Wales, Australia Sydney Eye Hospital, Sydney, Australia.

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http://dx.doi.org/10.1097/APO.0000000000000368DOI Listing
January 2021

Quality-of-life researchers in ocular allergy may benefit from the newer methods.

J Allergy Clin Immunol Pract 2021 Jan;9(1):595-596

Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/j.jaip.2020.09.067DOI Listing
January 2021

Bacterial Ocular Surveillance System (BOSS) Sydney, Australia 2017-2018.

Commun Dis Intell (2018) 2020 Oct 25;44. Epub 2020 Oct 25.

WHOCC for STI and AMR, NSW Health Pathology Microbiology, The Prince of Wales Hospital, Randwick, NSW, Australia.

Abstract: This study investigated antimicrobial resistance (AMR) profiles from a cohort of patients with bacterial keratitis treated at Sydney Eye Hospital, 1 January 2017 - 31 December 2018. These AMR profiles were analysed in the context of the current Australian empiric regimens for topical therapy: ciprofloxacin/ofloxacin monotherapy versus combination therapy of cefalotin/cephazolin plus gentamicin. At our Centre, combinations of (i) chloramphenicol plus gentamicin and (ii) chloramphenicol plus ciprofloxacin are alternatively used, so were also analysed. Three hundred and seventy-four isolates were cultured prospectively: 280/374 (75%) were gram positive, and 94/374 (25%) were gram negative. Coagulase-negative staphylococci comprised 173/374 (46%). Isolates included Staphylococcus aureus (n = 43/374) 11%; Streptococcus pneumoniae (n = 14/374) 3.7%; and Pseudomonas aeruginosa (n = 50/374) 13%. Statistical comparison was performed. There was no significant difference between cover provided either of the current Australian recommendations: ciprofloxacin/ofloxacin vs cefalotin/cephazolin plus gentamicin (5.3% vs 4.8%, respectively; p = 0.655). However, the combination of chloramphenicol plus an anti-pseudomonal agent (ciprofloxacin/ofloxacin or gentamicin) had significantly improved cover. Chloramphenicol plus gentamicin was superior to ciprofloxacin/ofloxacin (1.9% vs 5.3% resistance respectively; p = 0.007), and cefalotin/cephazolin plus gentamicin (1.9% vs 4.8%; p = 0.005). Chloramphenicol plus ciprofloxacin was superior to ciprofloxacin/ofloxacin monotherapy (1.3% vs 5.3%; p ≤ 0.001), and to cefalotin/cephazolin plus gentamicin (1.3% vs 4.8%; p = 0.003). Chloramphenicol plus gentamicin versus chloramphenicol plus ciprofloxacin/ofloxacin were equivalent (p = 0.48). There was no demonstrated in vitro superiority of either the current empiric antibiotic regimens. For our setting, for bacterial keratitis, chloramphenicol in combination offered superior in vitro cover. Broadened surveillance for ocular AMR is urgently needed across jurisdictions.
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http://dx.doi.org/10.33321/cdi.2020.44.86DOI Listing
October 2020

Travel associated microbial keratitis: is resistance a risk?

Travel Med Infect Dis 2020 Nov - Dec;38:101903. Epub 2020 Oct 28.

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health, Sydney, NSW, Australia; Sydney Eye Hospital, Sydney, Australia; School of Medical Sciences, University of New South Wales, Sydney, Australia.

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http://dx.doi.org/10.1016/j.tmaid.2020.101903DOI Listing
October 2020

Ocular trauma and prevention measures.

Clin Exp Ophthalmol 2020 Sep;48(7):875-876

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1111/ceo.13850DOI Listing
September 2020

Topical Steroids as Adjunctive Therapy for Bacterial Keratitis: Evidence From a Retrospective Case Series of 313 Cases.

Asia Pac J Ophthalmol (Phila) 2020 Sep-Oct;9(5):398-403

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia.

Purpose: The aim of this study was to report topical steroid usage in bacterial keratitis and analyze the effects of steroids on patients' outcomes to the main causative organisms.

Design: A retrospective case-series.

Methods: This study included all patients with corneal scrape positive bacterial keratitis from January 2012 to December 2016 at the Sydney Eye Hospital, Sydney, Australia. Cases were identified from pathology results and hospital coding, and data collected from medical records.

Results: A total of 313 eyes from 308 patients with a mean age of 51 years [interquartile range (IQR) 36-72] were included. Of these patients, 192 (61%) were treated with topical steroids. High-dose steroids were prescribed in 22 (11%) cases, regular-dose in 88 (46%), and low-dose in 82 (43%). The median time until the implementation of steroid use was 4 days (IQR 3-7). Patients prescribed with topical steroids had significantly longer healing times than the "no steroid" group (11 vs 6.5, P < 0.001). Patients with Pseudomonas aeruginosa keratitis and topical steroid use had worse clinical outcomes, with a higher proportion having longer healing times (P = 0.04) and corneal scarring (P = 0.02).

Conclusions: Adjuvant topical steroid therapy did not affect visual acuity, patient outcomes or the rate of adverse effects but may delay epithelial healing in bacterial keratitis in these patients. Topical steroids may have a differential effect depending on the specific causative organisms; however, a clinical trial is needed to assess this.
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http://dx.doi.org/10.1097/APO.0000000000000320DOI Listing
September 2020

Diagnosis using polymerase chain reaction and outcomes in herpes simplex keratitis.

Acta Ophthalmol 2020 Sep 15. Epub 2020 Sep 15.

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health, Sydney, NSW, Australia.

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http://dx.doi.org/10.1111/aos.14601DOI Listing
September 2020

Microbial keratitis in Sydney, Australia: risk factors, patient outcomes, and seasonal variation.

Graefes Arch Clin Exp Ophthalmol 2020 Aug 2;258(8):1745-1755. Epub 2020 May 2.

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, South Block, Level 1, 8 Macquarie St, Sydney, NSW, 2000, Australia.

Purpose: To provide recent data on patient demographics, clinical profile and outcomes of patients with microbial keratitis over a 5-year period at the Sydney Eye Hospital, and to identify seasonal variations of the main causative organisms.

Method: A retrospective study of patients with a clinical diagnosis of microbial keratitis and corneal scrape performed between 1 January 2012 and 31 December 2016. Clinical information was gathered from medical records and pathology data.

Results: One thousand fifty-two eyes from 979 patients with a mean age of 54.7 ± 21.5 years (range 18-100 years) were included. The majority of cases were bacterial (65%) followed by polymicrobial (2.4%), fungi (2.3%), and culture-negative (31%). Common risk factors for microbial keratitis were contact lens wear (63%) and previous topical steroid use (24%). Factors significantly associated with poor patient outcomes in the multivariate model were age, visual acuity, and epithelial defect size (p < 0.05). Patients with fungal or polymicrobial keratitis presented with worse clinical features at initial and final presentation (p < 0.05). There was a significant variation in the occurrence of Pseudomonas aeruginosa (p = 0.018) and fungal keratitis (predominately made up of Candida and Fusarium species) (p = 0.056) in the hottest seasons.

Conclusion: Poorer outcomes are more likely to be seen in older patients and those presenting with poor visual acuity and large epithelial defects at the initial presentation.
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http://dx.doi.org/10.1007/s00417-020-04681-0DOI Listing
August 2020

Bullying and harassment in ophthalmology: a trainee survey.

N Z Med J 2020 04 3;133(1512):102-103. Epub 2020 Apr 3.

Department of Ophthalmology, University of Auckland, Auckland.

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April 2020

Improving the Efficiency and the Technique of the Corneal Scrape Procedure via an Evidence Based Instructional Video at a Quaternary Referral Eye Hospital.

Curr Eye Res 2020 05 2;45(5):529-534. Epub 2020 Mar 2.

Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, Australia.

: Corneal culturing requires understanding of aseptic non-touch technique and avoidance of possible contaminants. Currently, there is no formal training in the technique and registrars are typically taught by another registrar in the emergency setting.The aim of the study was to develop an evidence-based instructional video for the corneal scrape procedure in microbial keratitis. The study then aims to assess the effect of the instructional video on clinician performance of the corneal scrape procedure.: An instructional video for corneal scraping was developed by identifying key steps for the procedure based on available evidence from a review of the literature and clinical practice. A prospective observational comparative case series that included clinicians at the Sydney Hospital/Sydney Eye Hospital, NSW Australia was conducted. Clinicians performing corneal scrapes had their performance of the procedure assessed prior to and after viewing the instructional video.: Sixteen key steps to follow in performing the corneal scrape procedure were found and demonstrated in the instructional video. Fourteen clinicians were observed performing 24 corneal scrapes in 24 patients with a median age of 56 years (IQR 34-65 years) and 45% male. Pre-video 11 scrapes were observed vs 13 scrapes post-video. Descriptive data were summarised and non-parametric categorical data analyzed using IBM SPSS (version 1.0.0.800) to perform chi-square and Wilcoxon signed-rank tests. Statistical significance was defined as < .05. The steps of the corneal scrape procedure were performed correctly by a greater number of clinicians post-video compared to pre-video ( = .003). There was a significant improvement in inoculation of agar plates with cross-hatched streaks (92% post- vs 55% pre-video) and the maintenance of an intact agar surface (92% post vs 55% pre-video) ( = .033).: An instructional video optimized the performance of corneal scraping, by ophthalmology trainees, in patients with microbial keratitis.
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http://dx.doi.org/10.1080/02713683.2019.1676910DOI Listing
May 2020

Development, Implementation, and Evaluation of Treatment Guidelines for Herpes Simplex Keratitis in Sydney, Australia.

Cornea 2020 Jul;39(7):834-840

Discipline of Ophthalmology, The University of Sydney, Save Sight Institute, Sydney Medical School, Sydney, New South Wales, Australia.

Purpose: To develop and measure the uptake of a local guideline for herpes simplex keratitis (HSK) and to standardize initial antiviral therapy in Australia.

Methods: The Registered Nurses' Association of Ontario Toolkit: "Implementation of Best Practice Guidelines" was used to develop, implement, and evaluate the guideline at Sydney Eye Hospital. An implementation team was established to reach consensus on antiviral therapy guidelines through review of available evidence, identifying stakeholders, facilitators and barriers, creating strategies for implementation, and developing a sustainability plan. An audit of all adult HSK cases during a 6-month postguideline implementation period was conducted, and the results were compared with a preimplementation audit. A web-based survey was created to assess clinician awareness, usage, and level of knowledge of the guideline.

Results: Clinicians, pharmacists, and administrative staff were identified as stakeholders. Changing clinician's behavior was the major barrier to implementation. Implementation strategies included printed and online materials and lectures to clinicians. A postimplementation audit included 85 patients, and 95 clinicians received a web-based survey. The dose of the prescribed antiviral medication was in alignment with the local guideline in 80% (51/64) of the patients compared with 73% (163/223) before implementation (P = 0.331). Stromal HSK with ulceration and keratouveitis were excluded because there were no recommendations before implementation. Over 70% of clinicians (30/41) were aware of the guideline and accessed them through educational resources.

Conclusions: Guidelines for the management of HSK may improve standardization of initial antiviral therapy in HSK. In practice, most clinicians were aware of and adhered to the local guideline.
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http://dx.doi.org/10.1097/ICO.0000000000002273DOI Listing
July 2020

Antimicrobial resistance trends in bacterial keratitis over 5 years in Sydney, Australia.

Clin Exp Ophthalmol 2020 03 19;48(2):183-191. Epub 2019 Nov 19.

Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.

Importance: Antimicrobial resistance (AMR) patterns in bacterial keratitis may fluctuate in a geographic location over time.

Background: To investigate any change in AMR patterns in Sydney, Australia.

Design: Retrospective case series.

Participants: All patients with microbial keratitis who underwent a corneal scrape and culture from 2012 to 2016 at the Sydney Eye Hospital.

Methods: Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry identified organisms. The Calibrated Dichotomous Susceptibility method determined antibiotic susceptibilities.

Main Outcome Measures: Isolated organisms and antibiotic susceptibilities.

Results: There were 1084 corneal scrapes from 957 patients. The mean age was 54 years (range 18-100) and 52% were male. Cultures were positive in 711 of 1084 scrapes (66%), with 884 organisms identified. Of the bacteria isolated, 685 of 884 (78%) were Gram-positive and 199 of 884 (22%) were Gram-negative. Overall, the most common bacteria were coagulase-negative Staphylococci (CoNS) (405/884, 46%). Methicillin-resistance was detected in 7% of Staphylococcus aureus isolates (7/103). Methicillin-resistance in CoNS (ie, also cefalotin resistance) was reported in 19% of isolates and ciprofloxacin 8%. For methicillin-sensitive S aureus (MSSA), 5% of isolates were resistant to ciprofloxacin. For Corynebacterium spp., 34% of isolates were resistant to chloramphenicol and 9% to ciprofloxacin. The most common Gram-negative bacteria was Pseudomonas aeruginosa (109/199, 55%). One case was resistant to ciprofloxacin.

Conclusions And Relevance: Coagulase-negative staphylococcal species were the most frequently suspected of causing bacterial keratitis. Increased resistance to cefalotin was identified for CoNS and to ciprofloxacin for Corynebacterium spp., MSSA and P aeruginosa compared to a previous study in Sydney in 2002 to 2003.
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http://dx.doi.org/10.1111/ceo.13672DOI Listing
March 2020

Psychometric Properties of the Keratoconus Outcomes Research Questionnaire: A Save Sight Keratoconus Registry Study.

Cornea 2020 Mar;39(3):303-310

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia.

Purpose: The aim of this study was to evaluate the psychometric properties of the Keratoconus Outcomes Research Questionnaire (KORQ) in patients enrolled in the Save Sight Keratoconus Registry.

Methods: A cross-sectional study was conducted utilizing prospectively collected web-based registry data. The psychometric properties of the KORQ were assessed using both classical test theory and Rasch analysis. Andrich group rating scale variant of the Rasch analysis was conducted using Winsteps software, Version 3.92.1.

Results: The KORQ was completed by 189 patients with keratoconus (men, 67.7%; white, 69.8%; median age 29 years; better eye median values: visual acuity, 75 LogMAR letters; Kmax, 51.3 D; K2, 46.5 D; thinnest pachymetry, 485 μm). Cronbach's α for the "Activity Limitation" and "Symptoms" scales were 0.95 and 0.91, respectively, with both scales free from floor or ceiling effects. On Rasch analysis, the category thresholds were ordered and well-spaced for both scales. The Activity Limitation scale had excellent psychometric properties including person separation index (3.6), unidimensionality (variance explained, 65.4%), fit statistics (<1.3 MnSq), and measurement range (3.6 logits). Similarly, the Symptoms scale had satisfactory psychometric properties including person separation index (2.5), unidimensionality (variance explained, 54.3%), fit statistics (<1.30 MnSq except for 1 item), and measurement range (2.0 logits). Both scales were well targeted to the population and free of differential item functioning.

Conclusions: The KORQ is a psychometrically robust patient-reported outcome measure for evaluating quality of life parameters in keratoconus. It enables routine collection and monitoring of meaningful patient-reported outcome data in clinical settings, including registries.
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http://dx.doi.org/10.1097/ICO.0000000000002169DOI Listing
March 2020

Measurement of Quality of Life in Keratoconus.

Cornea 2020 Mar;39(3):386-393

Discipline of Ophthalmology, Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; and.

Purpose: To identify and assess the quality of questionnaires used to measure quality of life in keratoconus and guide selection of the most appropriate questionnaire for evaluating the impact of keratoconus.

Methods: A literature search was carried out in Scopus, Web of Science, PubMed, MEDLINE, Cochrane, and PsycINFO databases. Articles that described a questionnaire to measure quality of life in keratoconus were included. Information on psychometric properties and validity was extracted and analyzed based on a set of quality criteria. Finally, the impact of keratoconus and its management methods on quality of life was reviewed.

Results: The search yielded 331 publications, of which 45 articles describing 18 (12 ophthalmic including 2 keratoconus-specific and 6 generic) questionnaires were reviewed. Most of the articles (40, 88.9%) described ophthalmic questionnaires not specific to keratoconus. The National Eye Institute Visual Function Questionnaire was the most frequently used questionnaire (n = 26). Only 4 articles provided information on psychometric properties. The Keratoconus Outcomes Research Questionnaire, the only validated keratoconus-specific questionnaire, had the most superior psychometric properties. However, it consists of items on only 2 domains of quality of life (activity limitation and symptoms). Overall, keratoconus management methods (spectacles, contact lenses, and cross-linking in early stages, corneal transplantation in late stages) improved quality of life. The quality of life scores were associated with clinical measures including visual acuity, corneal topography, pachymetry, and keratoconus severity.

Conclusions: There is a need for a comprehensive and high-quality patient-reported outcome measure in keratoconus. A questionnaire should be chosen based on the purpose and the quality of the questionnaire. This review guides selection of an appropriate questionnaire.
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http://dx.doi.org/10.1097/ICO.0000000000002170DOI Listing
March 2020

Are current ophthalmology clinical practices relating to blue light-filtering intraocular lenses evidence-based?

Clin Exp Ophthalmol 2020 01 22;48(1):125-127. Epub 2019 Oct 22.

Department of Optometry and Vision Sciences, The University of Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ceo.13653DOI Listing
January 2020

The Impact on Work Patterns of Implementing the Save Sight Keratoconus Registry in the Hospital Setting.

Cornea 2020 Apr;39(4):451-456

Discipline of Ophthalmology, The University of Sydney, Save Sight Institute, Sydney Medical School, Sydney, New South Wales, Australia.

Purpose: The adoption of clinical registries has the potential to improve outcomes, while reducing the costs of health care. We sought to evaluate the changes in workflow that occurred with implementation of the Save Sight Keratoconus Registry (SSKR) in corneal clinics.

Methods: A prospective time-motion study and a clinician survey were conducted. The timing of clinic consultations was recorded before and after implementation of the SSKR. The activities were assigned into 3 main categories: 1) direct patient care (eg, talking to, examining), 2) indirect patient care (record keeping), and 3) indirect patient care (reading).

Results: Overall, there was no change in average time spent per patient with or without the SSKR; 12.3 (5.3 SD) versus 12.1 (5.3 SD) minutes, respectively, P = 0.84. There was no change in time spent providing direct care with or without the SSKR; 5.4 (2.8 SD) versus 5.9 (2.8 SD) minutes, respectively, P = 0.51. Within direct patient care, there was no impact with or without the SSKR on the time spent examining (1.9 [1.0 SD] vs. 1.9 [1.4 SD] minutes, respectively, P = 0.58) or talking to patients (3.5 [2.3 SD] vs. 4.1 [2.3 SD] minutes, respectively, P = 0.21). Indirect care time was unchanged overall for record keeping (3.2 [2.2 SD] vs. 4.6 [2.9 SD], respectively, P = 0.16) and reading tasks (3.1 [1.8 SD] vs. 2.0 [1.3 SD], respectively, P = 0.09).

Conclusions: The SSKR was implemented into clinical practice without affecting the total consultation time, time spent directly interacting with patients, or use of patient records. Our findings support that registries requiring data entry could be widely adopted into routine clinical practice.
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http://dx.doi.org/10.1097/ICO.0000000000002159DOI Listing
April 2020

The clinical and microbiological features and outcomes of fungal keratitis over 9 years in Sydney, Australia.

Mycoses 2020 Jan 27;63(1):43-51. Epub 2019 Oct 27.

New South Wales Health Pathology Microbiology, Randwick, NSW, Australia.

To describe the clinical features, management and outcomes in patients with fungal keratitis at the Sydney Eye Hospital, Australia, over a 9-year period to guide appropriate initial therapy. A retrospective case review was conducted. Patients diagnosed with fungal keratitis from 1 January 2009 to 31 December 2017 were identified from hospital coding and pathology databases. Data were extracted from the medical records. A total of 55 episodes from 51 patients were included. Mean age was 60 ± 20 years (range: 19-91 years), and 33 were male. The fungal species was not identified in two patients. Predisposing factors included ocular surface disease in 17 eyes (32%); corneal disease, 15 (28%); corneal trauma, 12 (23%); and contact lens wear, 13 (24.5%). Fusarium spp. (15, 27%) and Candida parapsilosis (10, 18%) were the most common isolates. The median visual acuity at presentation was 1.3 logMAR (range: 0 to 3) and after treatment 0.7 logMAR (range: -0.02 to 3) (P = .008). Despite medical therapy, most commonly with natamycin and topical and oral voriconazole, surgical intervention was required in 21 eyes (40%); including antifungal injections in 9 (16%); corneal transplantation, 16 (30%); evisceration, 2 (4%); and enucleation, 1 (2%). A poor visual outcome was recorded in 27 of 43 (63%) patients. Fungal keratitis remains a cause of significant ocular morbidity; the majority of patients face a poor outcome despite intense medical and at times surgical treatment. In our setting, fungal keratitis was more commonly associated with corneal or ocular surface disease.
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http://dx.doi.org/10.1111/myc.13009DOI Listing
January 2020

Eye injury registries - A systematic review.

Injury 2019 Nov 26;50(11):1839-1846. Epub 2019 Jul 26.

The School of Optometry and Vision Science, UNSW, Sydney, New South Wales, Australia; The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia.

Objectives: Registries are integral to monitoring, surveying, treating, preventing and prognosticating trauma. The quantity and quality of data must justify a change or intervention in treatment and/or preventive strategies and must be collected while balancing the cost and time invested in the registry. This review documents the quality, completeness and operational and funding models for ocular trauma registries worldwide.

Methods: The databases CENTRAL, MEDLINE, EMBASE and Informit Health Collection were searched using key word and mesh terms for: "Eye injury, "Ocular trauma", "Eye injury prevention", "Eye protection", "Registry". To find relevant unpublished articles and theses, clinicaltrials.gov, Trip, MedNar and Google Scholar were searched using the key words "eye injury" OR "ocular trauma" AND "registry*". No date or language restrictions were applied. The quality of registry data was assessed against published measures including design, operation and data quality.

Results: The electronic search retrieved 528 distinct published articles; 61 articles were assessed for eligibility. Of the 61 articles identified, 28 were eligible to be included in the review, with cross-referencing identifying a further 7 articles. The source of most articles on ocular trauma registries was the United States, followed by Germany and China. Patient follow-up was conducted in 31 studies, with 6 months being the most frequently reported period. Issues with data quality included incomplete data such as presence or absence of eye protection and initial visual acuity. Attrition bias was controlled by the United States Eye Injury Register with follow-up. Patients without follow-up data were removed for some studies and this may have introduced bias.

Conclusion: National, state and hospital-based ocular trauma registries have contributed significantly to our understanding of ocular trauma. The United States has the most frequently cited and well-resourced ocular trauma registries. It is anticipated that this review will guide the development of future registries for ocular trauma in order to inform evidence-based prevention strategies and, ultimately, improve visual outcomes. We recommend the development of a consensus guidelines for international ocular trauma registry that includes mechanism and context of injury and visual outcomes, to permit international comparison that can be implemented at low cost with secure data capture.
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http://dx.doi.org/10.1016/j.injury.2019.07.019DOI Listing
November 2019

Keratoconus Natural Progression: A Systematic Review and Meta-analysis of 11 529 Eyes.

Ophthalmology 2019 07 8;126(7):935-945. Epub 2019 Mar 8.

The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia.

Purpose: We set out to describe the natural history of keratoconus. We included untreated patients, and our key outcome measures were vision, refraction, and corneal curvature.

Clinical Relevance: Keratoconus affects 86 in 100 000 people, causing visual loss due to increasing irregular corneal astigmatism, and the quality of life declines in patients. Interventions are used to stabilize the disease or improve vision, including corneal cross-linking (CXL) and grafting, but these carry risks. Detailed knowledge of the natural history of keratoconus is fundamental in making informed decisions on when their benefits outweigh these risks.

Methods: We included prospective or retrospective studies of pediatric or adult patients who reported 1 or more of visual acuity, refraction, and corneal curvature measures: steep keratometry (K), mean keratometry (K), or maximum keratometry (K), thinnest pachymetry, corneal transplantation rates, corneal scarring incidence, and patient-reported outcome measures (PROMs). Databases analyzed included Medline, Embase, CENTRAL, and CINAHL. Searches were carried out until October 2018. Bias assessment was carried out using the Joanna Briggs Institute model of evidence-based healthcare.

Results: Our search yielded 3950 publication titles, of which 41 were included in our systematic review and 23 were incorporated into the meta-analysis. Younger patients and those with greater K demonstrated more steepening of K at 12 months. The meta-analysis for K demonstrated a significant increase in K of 0.7 diopters (D) at 12 months (95% confidence interval [CI], 0.31-1.14; P = 0.003). Our meta-regression model predicted that patients had 0.8 D less K steepening over 12 months for every 10-year increase in age (P = 0.01). Patients were predicted to have 1 D greater K steepening for every 5 D of greater baseline K (P = 0.003). At 12 months, there was a significant increase in the average K of 0.4 D (95% CI, 0.18-0.65; P = 0.004).

Conclusions: We report the first systematic review and meta-analysis of keratoconus natural history data including 11 529 eyes. Younger patients and those with K steeper than 55 D at presentation have a significantly greater risk of progression of keratoconus. Closer follow-up and a lower threshold for cross-linking should be adopted in patients younger than 17 years and steeper than 55 D K.
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http://dx.doi.org/10.1016/j.ophtha.2019.02.029DOI Listing
July 2019

Gender differences in Australasian ophthalmologists' experiences of the workplace.

Clin Exp Ophthalmol 2019 08 20;47(6):706-712. Epub 2019 Mar 20.

Department of Ophthalmology, The University of Auckland, Auckland, New Zealand.

Importance: Gender differences were identified in experiences of the workplace and family responsibilities amongst Australian and New Zealand ophthalmologists.

Background: To survey ophthalmologists regarding their balance of career, family and workplace experiences and to identify gender differences.

Design: Online questionnaire sent to 1000 randomly selected Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Fellows in 2017.

Participants: The response rate was 28% (n = 282) with 192 males.

Methods: Confidential questionnaire.

Main Outcome Measures: Questionnaire responses.

Results: Gender differences were noted in working hours (59% of males worked greater than 40 hours a week vs 26% of females, P < 0.001) and frequency of private practice work (mean of 6.6 half-day sessions per week for men vs 4.9 sessions for women, P < 0.001). Female ophthalmologists reported additional obstacles to career advancement including difficulty receiving mentorship (57% vs 40%, P = 0.027), travel difficulties due to family responsibilities (59% vs 34%, P < 0.001) and rigid timelines for promotion/tenure (38% vs 19%, P = 0.005). Female ophthalmologists delayed child-bearing, with 59% becoming parents after fellowship training. Women spent more time child-rearing (67% vs 8% of men cared for children >20 hours per week, P < 0.001). Female ophthalmologists were more likely to report experiencing discrimination (31% vs 8% of men, P < 0.001).

Conclusions And Relevance: Female ophthalmologists worked fewer hours, mainly in the private sector, to fulfil their greater family commitments. Female ophthalmologists reported additional obstacles to career advancement and were more likely to report experiencing discrimination in the workplace.
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http://dx.doi.org/10.1111/ceo.13487DOI Listing
August 2019

Vision-Related Quality of Life in Keratoconus: A Save Sight Keratoconus Registry Study.

Cornea 2019 May;38(5):600-604

Save Sight Institute, University of Sydney, Sydney, Australia.

Purpose: To assess vision-related quality of life using the Impact of Vision Impairment Questionnaire (IVI) in patients with keratoconus enrolled in the Save Sight Keratoconus Registry.

Methods: In this cross-sectional study, data on 107 keratoconic patients were collected through a prospectively designed web-based registry from a quaternary referral eye hospital and 2 corneal subspecialty practices. Vision-related quality of life was evaluated using the IVI. Rasch analysis was used to transform the IVI responses into interval-level measures comprising reading, mobility, and emotional well-being subscales. Associations between best-corrected visual acuity (BCVA), maximum simulated keratometry (Kmax), steep keratometry (K2), and pachymetry for each eye and IVI subscale scores were evaluated with univariate (Pearson correlations) and multivariable regression adjusted for age and gender.

Results: Of the 107 patients, 37 (34.5%), 41 (38.0%) and 29 (26.9%) had mild, moderate, and severe keratoconus, respectively. On uni- and multivariable analysis, BCVA in the better eye had the strongest association with reading [r = 0.51; 95% confidence interval (CI), 0.35-0.64, P = 0.004] and mobility (r = 0.55; 95% CI, 0.41-0.67, P < 0.001) subscale scores. BCVA in the better and worse eye, both had the joint strongest associations with emotional scores on univariate analysis, but only the latter was significant on multivariable analysis (r = 0.37; 95% CI, 0.20-0.53, P < 0.001). K2 and Kmax in the better eye also displayed significant associations with reading and mobility scores.

Conclusions: In patients with keratoconus, BCVA in the better eye had the strongest correlation with reading and mobility scores, whereas BCVA in the worse eye was significantly correlated with emotional scores.
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http://dx.doi.org/10.1097/ICO.0000000000001899DOI Listing
May 2019

Statins in ophthalmology.

Surv Ophthalmol 2019 May - Jun;64(3):401-432. Epub 2019 Jan 28.

Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia.

Statins, 3-hydroxy-3-methyl-gutaryl coenzyme A reductase inhibitors, are a class of lipid-lowering drugs with anti-inflammatory, immunomodulatory, and vascular effects. Statins are increasingly being used in the treatment of a variety of medical conditions. We examine the actions of statins on the eye and its associated ophthalmic disorders. Statins can be synthetic or nonsynthetic, and their differentiating derivations may contribute to their varying cholesterol-lowering and pleiotropic effects. There is conflicting evidence on the ocular therapeutic and adverse effects of the statins. Statins may play a role in reducing the burden of dry eye, corneal ulcer scarring, thyroid-associated orbitopathy, glaucoma, uveitis and other associated ocular inflammatory states, cataract, proliferative vitreoretinopathy, diabetic retinopathy, macular degeneration, and choroidal melanoma. Topical preparations of statins can be formulated, thereby extending the range of ocular diseases that may be amenable to treatment. Statins have a relatively safe side effect profile, but rare and serious adverse reactions have been reported with their usage in ophthalmology, including myopathies and rhabdomyolysis with acute renal failure.
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http://dx.doi.org/10.1016/j.survophthal.2019.01.013DOI Listing
December 2019

HMG-CoA reductase expression in human eyelid tissue and in a human meibomian gland epithelial cell line.

Graefes Arch Clin Exp Ophthalmol 2019 Apr 21;257(4):785-790. Epub 2019 Jan 21.

Save Sight Institute, University of Sydney, Sydney Eye Hospital Campus, 8 Macquarie Street, Sydney, NSW, 2000, Australia.

Purpose: 3-Hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR), the rate-limiting enzyme of cholesterol production, has been found to contribute to lipid secretion from skin sebaceous glands and hair follicles. We assessed for HMGCR expression in human eyelid tissue and in immortalized human meibomian gland epithelial cells (HMGECs) using immunohistochemistry.

Methods: Full thickness human eyelid specimens in archival paraffin blocks were obtained. A section from each block was stained with hematoxylin and eosin and examined by an ocular pathologist for validation of tissue pathology. Immunohistochemistry was performed using rabbit anti-human HMGCR antibody on serial sections using the Ventana automated staining system. HMGCR expression was examined for in HMEGCs with fluorescence immunocytochemistry and confocal microscopy.

Results: Thirteen full thickness eyelid specimens met the inclusion criteria. All specimens contained meibomian glands, and 2 (15%) contained glands of Zeis, 3 (23%) pilosebaceous glands, 2 (15%), accessory lacrimal glands, and 2 (15%), glands of Moll, respectively. Immunohistochemistry showed HMGCR expression in meibocytes of meibomian glands and sebocytes of Zeis and pilosebaceous glands in all specimens. HMGCR expression was also evident in vascular endothelium. Immunofluorescence was positive for HMGCR expression on HMGEC cells. No labeling was seen for the negative Ig control.

Conclusion: HMGCR was expressed in all eyelid sebaceous-type glands and in HMGECs, consistent with a role for cholesterol production in the genesis of tear film lipids. The observed expression also provides a rationale for using topical statins, inhibitors of HMGCR, as novel tear film lipid stabilizers in conditions such as blepharitis, where meibum production is aberrant.
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http://dx.doi.org/10.1007/s00417-019-04247-9DOI Listing
April 2019

Clinical Registries in Ophthalmology.

Ophthalmology 2019 05 17;126(5):655-662. Epub 2018 Dec 17.

Save Sight Institute, University of Sydney, Sydney, Australia; Sydney Eye Hospital, Sydney, Australia.

Topic: Clinical registries in ophthalmology.

Clinical Relevance: In recent years, advancements in digital technology and increasing use of electronic medical records in health systems have led to the dramatic growth in large clinical data sets. Clinical data registries are organized systems that collect data on patients diagnosed with a disease or condition or who undergo a certain procedure.

Methods: A search of the PUBMED database was conducted in January 2018 for clinical registries in ophthalmology.

Results: Ninety-seven clinical eye registries were found, with significant growth in numbers in the last 4 decades. The most common conditions captured were blindness or low vision, corneal transplantation, glaucoma, and cataract surgery. Most registries originate in the European region, North America, and Australia. Nine registries had multinational coverage, whereas 48 were national registries. As the numbers and scope of clinical registries have expanded, valuable observational data have been used to study real-world clinical outcomes in healthcare quality measurement and improvement and to develop new guidelines and standards. Pertinent areas of its use include studying treatments and outcomes in cataract surgery, corneal transplantation, and macular degeneration.

Conclusions: The use of clinical registries for quality improvement and research has grown significantly in the last few decades, and this trend will continue as information technology infrastructures develop.
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http://dx.doi.org/10.1016/j.ophtha.2018.12.030DOI Listing
May 2019

Visualizing the Contribution of Keratin-14 Limbal Epithelial Precursors in Corneal Wound Healing.

Stem Cell Reports 2019 01 13;12(1):14-28. Epub 2018 Dec 13.

Mechanisms of Disease and Translational Research, School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia. Electronic address:

It is thought that corneal epithelial injuries resolve by leading-edge cells "sliding" or "rolling" into the wound bed. Here, we challenge this notion and show by real-time imaging that corneal wounds initially heal by "basal cell migration." The K14CreER-Confetti multi-colored reporter mouse was employed to spatially and temporally fate-map cellular behavior during corneal wound healing. Keratin-14 basal epithelia are forced into the wound bed by increased population pressure gradient from the limbus to the wound edge. As the defect resolves, centripetally migrating epithelia decelerate and replication in the periphery is reduced. With time, keratin-14-derived clones diminish in number concomitant with their expansion, indicative that clonal evolution aligns with neutral drifting. These findings have important implications for the involvement of stem cells in acute tissue regeneration, in key sensory tissues such as the cornea.
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http://dx.doi.org/10.1016/j.stemcr.2018.11.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6335450PMC
January 2019

Central corneal thickness changes and horizontal corneal diameter in premature infants: A prospective analysis.

Medicine (Baltimore) 2018 Nov;97(48):e13357

Central Clinical School, Camperdown.

To report observations of horizontal corneal diameter (HCD) and central corneal thickness (CCT) changes in premature infants with stable optic disc cupping and intraocular pressures (IOPs). The HCD and CCT at term serve as a baseline for premature infants.Sixty-three premature infants were enrolled in a prospective case series. HCD, CCT, and IOP were measured. RetCam images of the optic discs were used to evaluate the cup-disc ratio (CDR) and read by an independent masked observer. Data were collected at between preterm (32-36 weeks) and again at term (37-41 weeks) postconceptual age. Left eye measurements were used for statistical analysis. Left eye findings were combined to construct predictive models for HCD and CCT.The mean HCD was 9.1 mm (standard deviation [SD] = 0.7 mm) at preterm and 10.0 mm (SD = 0.52 mm) at term. The mean CCT preterm was 618.8 (SD = 72.9) μm and at term 563.9 (SD = 50.7) μm, respectively. The average preterm CDR was 0.31 and at maturity was 0.33. Average IOP of preterm and term was 13.1 and 14.11 mm Hg, respectively. There was significant linear correlation between HCD with the postmenstrual age (r = 0.40, P < .01) and the head circumference (r = 0.33, P < .05). Predictive models were constructed for HCD (R = 0.52, 0.2 mm/wk) and CCT (R = 0.23, -11.4 μm/wk) with postconceptual ages.The HCD and CCT variation did not affect IOP reading over time. CCT was not correlated with birth parameters and decreased as the infant reached term. Corneal diameter correlated with gestational age at birth and head circumference.
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http://dx.doi.org/10.1097/MD.0000000000013357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6283202PMC
November 2018