research topics in eye care

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• Indian J Ophthalmol
• v.68(2); 2020 Feb

Comprehensive eye care - Issues, challenges, and way forward

Maria vittoria cicinelli.

1 Department of Ophthalmology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy

Srinivas Marmamula

2 Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, L V Prasad Eye Institute, Hyderabad, Telangana, India

3 Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, Telangana, India

4 Senior Visiting Fellow - School of Optometry and Vision Science, University of New South Wales, Sydney, Australia

5 Wellcome Trust / Department of Bio-technology India Alliance fellow, L V Prasad Eye Institute, Hyderabad, Telangana, India

Rohit C Khanna

As we move from a disease-specific care model toward comprehensive eye care (CEC), there is a need for a more holistic and integrated approach involving the health system. It should encompass not only treatment, but also prevention, promotion, and rehabilitation of incurable blindness. Although a few models already exist, the majority of health systems still face the challenges in the implementation of CEC, mainly due to political, economic, and logistic barriers. Shortage of eye care human resources, lack of educational skills, paucity of funds, limited access to instrumentation and treatment modalities, poor outreach, lack of transportation, and fear of surgery represent the major barriers to its large-scale diffusion. In most low- and middle-income countries, primary eye care services are defective and are inadequately integrated into primary health care and national health systems. Social, economic, and demographic factors such as age, gender, place of residence, personal incomes, ethnicity, political status, and health status also reduce the potential of success of any intervention. This article highlights these issues and demonstrates the way forward to address them by strengthening the health system as well as leveraging technological innovations to facilitate further care.

Vision impairment (VI) is a major global health concern, as it is associated with a diminished quality of life[ 1 ] and decreased survival expectancy in the middle-aged and elderly population.[ 2 ] Recent global data shows that there are 36 million blinds and 217 million moderately and severely visually impaired people.[ 3 ] Compared to 1990, though the prevalence of blindness and moderate and severe VI has decreased, the absolute number of blind persons has increased by 17.6% and moderate to severe VI has increased by 35%.[ 3 , 4 ] The economic burden of blindness, due to both direct and indirect costs, makes it extremely important to allocate adequate resources and invest in prevention, treatment, and rehabilitation programmes.[ 5 ] A significant shift in prevalence and causes of VI since the beginning of the 21 st century has occurred, from relatively easy and cost-effective treatable conditions like cataract, uncorrected refractive error (URE), trachoma, onchocerciasis, to chronic diseases, globally termed as noncommunicable eye diseases (NCEDs).[ 6 ] The consequences of global eye health planning are straightforward: vertically running, stand-alone programs focusing on a specific disease rather than addressing the person as a whole cannot be effective any longer. The solution is to provide a comprehensive eye care (CEC) strategy,[ 7 ] based on integrated, multilevel models of eye care delivery (from primary to advanced tertiary levels of care), using the Health System approach and addressing all causes of blindness.[ 8 ] A comprehensive approach to eye care involves not only treatment, but also encompasses prevention, promotion, and rehabilitation for the incurable blindness as well as integrating with other stakeholders in the community. According to WHO, CEC is indented as the strategy which “aims to ensure that people have access to eye care services that meet their needs at every stage of life. This includes not only prevention and treatment services, but also vision rehabilitation. CEC care also aims to address the full spectrum of eye diseases.”[ 9 ]

Starting from this definition, the aim of this review is to illustrate the main features of CEC models, illustrate certain case studies, and to analyze the major challenges that have to be faced to ensure its global diffusion. A PubMed engine search was carried out using the terms “comprehensive eye care”, “primary eye care”, and “comprehensive ophthalmology”. All studies published in English up to December 2018, irrespective of their online publication status, were included in this review. These data were integrated with personal knowledge and peer communications and reports available on dedicated websites.

The Demographic Transition and Non-communicable Eye Diseases (NCED)

Since the launch of VISION 2020: The Right to Sight initiative in 1999, the achievements in terms of elimination of preventable blindness have been encouraging.[ 10 , 11 ] During the last decades, most of the global prevention programmes have focused on public health conditions, such as trachoma, onchocerciasis, and vitamin A deficiency, which have been addressed with specific control measures.[ 12 ] Specifically, onchocerciasis was eliminated in Africa and Latin America thanks to three major programmes: the Onchocerciasis Control Program (OCP), the African Program for Onchocerciasis Control (APOC), and the Onchocerciasis Elimination Program of America (OEPA). The WHO established the Alliance for Global Elimination of Trachoma (GET) by year 2020 in 1997, while the World Health Assembly (WHA) adopted a resolution in 1998 to eliminate trachoma by 2020 through the SAFE (Surgery, Antibiotics, Facial cleanliness and Environmental change) strategy. Thanks to these projects, elimination of trachoma has been achieved in many areas where the disease was endemic. Sustained political commitment of national governments, global partnerships, private–public philanthropy, non-governmental organizations (NGOs), and community support were the major reasons for success of these programs. Outstanding examples of philanthropic support include the donation of medicines like ivermectin by Merck and of azithromycin by Pfizer that were pivotal for effective control of onchocerciasis and trachoma.[ 12 ] Apart from these cases, the most visible partnership is the joint global initiative of the World Health Organization (WHO) and International Agency for the Prevention of Blindness (IAPB) for the elimination of avoidable blindness, VISION 2020: The Right to Sight.[ 11 ]

Large-scale cataract surgical programs in developing countries have been another successful step in the fight against world blindness in the period 1990–2010.[ 13 ] Wang et al . demonstrated the direct relationship between the cataract surgical rates (CSR) of a country and its per capita gross domestic product (GDP) and gross national income (GNI),[ 14 ] illustrating the impact of resource availability on the delivery of eye care. In India and Nepal, success has been achieved thanks to a combination of involvement of the ophthalmology leadership coupled with international funding, as well as the collaborative efforts between the government, NGOs, and the private sector. The formation of the District Blindness Control Society (DBCS) was one initiative that led to decentralization of planning and program implementation, resulting in increased output. A total of 15.3 million cataract operations were performed between 1995 and 2002, through the World Bank–supported Cataract Blindness Control Project, considerably reducing the burden of this condition in India.[ 15 ]

All the above examples for controlling diseases like trachoma, onchocerciasis, and cataract highlight the critical factors involved in the control of blindness and VI from a specific disease. Some of these conditions might be cleared with a one-time intervention (surgery for cataract and systemic antibiotics for trachoma); however, they need a periodic follow-up for longer community health measures. Conversely, NCEDs like glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy (DR), as well as emerging ocular conditions, such as childhood blindness (pediatric cataract, congenital glaucoma, tumors, retinopathy of prematurity [ROP]), myopic degeneration, macular hole, and optic neuritis, need not only more competent diagnostic skills, but also lifelong follow-up care as well as referral across different specialties. The same holds true for many other non-blinding diseases, like dry eye, allergic conjunctivitis, uveitis, and oculoplastic and orbital conditions. These conditions also require ongoing follow-up care as well as compliance to therapy.

The relative prevalence of NCEDs and the above listed emerging conditions has been increasing in the last decade. As age is the main risk factor for many NCEDs, especially glaucoma, AMD and cataract, these changes can be relatively well-explained by the global population growth and the increased life expectancy. In addition, the nutritional and lifestyle transformations have led to a demographic and epidemiologic transition toward a less-active and more urbanized generation, with completely different health demands. For instance, the reduction in the global amount of time spent outdoor and the shift towards new highly caloric food regimens have been linked to an a raising prevalence of myopia and increased rate of obesity (and therefore type 2 diabetes and DR).[ 16 ] These changes have already taken place in high-income countries, and now are progressively becoming more frequent in low- and middle-income countries (LMICs).[ 17 ] Projections for these chronic NCEDs are alarming and can have devastating consequences on health if not identified and controlled at the earlier stage. For example, there were 382 million people with diabetes in 2013 and projections for 2035 were 592 million.[ 18 ] This will have implications on DR too. Similarly, there were approximately 65 million people with glaucoma in 2013 with projections being more than 110 million by 2040,[ 19 ] and 196 million people with ARMD in 2020 with projections for 2040 being 288 million.[ 20 ] At the same time, there is also increase in the global prevalence of conditions like myopia. There are approximately, 1.5 billion people with myopia and 163 million people with high myopia. Projections for 2050 is approximately 5 billion with 1 billion having high myopia.[ 16 ] Intervention for myopia again needs an integrated approach and should also involve other sectors in health as well as education. Similarly, there are 1.8 billion people with presbyopia, with nearly 50% of these people without appropriate spectacle near correction.[ 21 ]

The Comprehensive Eye Care

Dealing with chronic conditions is challenging: a single medical intervention (either medical, with antibiotics or spectacles; or surgical, with cataract extraction) is not enough to restore vision in these scenarios. There is a need for repeated follow-up as well as life-long therapies. There is also the need to integrate with other stakeholders in the health system. At times, NCEDs are incurable, and the response to available treatment is often unpredictable and unsatisfactory. Considering the challenges related to high treatment costs, need for regular follow-up, interaction with other healthcare sectors and patients' cooperation and compliance, it is not difficult to understand how NCEDs often result in permanent and severe visual loss.[ 22 , 23 ] Currently, a significant proportion of these problems are treated at the tertiary level and guidelines for their management using public health approaches at primary level is limited.[ 24 ] However, recently, these services are also being offered at primary and secondary level of care.[ 25 , 26 ] Most of these models are using teleophthalmology for screening, consulting, and triage for conditions like DR and glaucoma.[ 27 ]

CEC models are critical to face NCEDs; this strategy of providing eye care is based on an integrated multilevel structure [ Fig. 1 ].[ 28 ] They include:

The pyramidal structure of comprehensive eye care (CEC)

• Comprehensive eye examination , which refers to a relevant series of evaluations (visual acuity, anterior segment, and posterior segment) conducted for a patient with an eye problem
• Comprehensive eye care services , which include eye health promotion; prevention, diagnosis, and treatment of eye diseases (primary eye care, PEC) and rehabilitation of those with irreversible blindness and low vision
• Comprehensive eye care system , designed to provide the services as mentioned above equally to different groups (related to age, sex, location, genetic tract, and economic status) irrespectively to the complexity and cost of care.

The chances of success of CEC depend on the combination of six building blocks proposed by WHO as frameworks for health systems strengthening [ Fig. 2 ].[ 7 ]

Building blocks of comprehensive eye care (CEC). Source: Blanchet K, Patel D. Indian J Ophthalmol. 2012 Sep-Oct; 60 (5):470-4

• Human resources: An “Eye Care Team” approach needs to be adapted. It is necessary to have ophthalmologists well-trained to perform comprehensive eye examinations, provide or initiate medical treatment for the majority of diseases, and conduct surgical procedures up to secondary-level services, including cataract, glaucoma, and some corneal and oculoplastic procedures. He/she is supported by a range of mid-level ophthalmic personnel including nurses, optometrists, technicians, and administrative staff who aid with surgery, rehabilitation, PEC, and management planning. Respectively there are also systems for continuous professional development (CPD) for the staff. The eye care providers are able to judge appropriately those cases which should be referred for advanced care and are oriented towards long-term care and support; there is also need of provision for a two-way referral, so that those referred to tertiary care centers or higher level of care can be followed-up back. Moreover, they adopt a patient-centered approach, including patient training to increase adherence to treatment regimens (this is especially important when managing diseases like DR and glaucoma and other chronic eye conditions, where patients need to comply with life-long treatments and follow-up)
• Service delivery: The CEC services are comprehensive in disease control, population coverage and referrals; they are also of high-quality, equitable, accessible, and affordable. Eye care providers offer the entire spectrum of eye services, from promotion to treatment, in a continuous manner across levels of care, settings, and providers, rather than as a one-time activity. They also deliver rehabilitation programs to irreversibly blind people, empowering them to continue to live independently and maintain their accustomed quality of life. Low vision rehabilitation services are provided at all levels of eye care, to guarantee complete fruition; if not, an efficient referral pathway is established within the hospital system. Finally, CEC systems run both vertically and horizontally: they are imbricated with other medical facilities to guarantee prompt referral of patients who need multidisciplinary management and are also vertically integrated across the primary, secondary, and tertiary levels of care

CEC services require equitable access to essential medical products and technologies of assured quality, safety, efficacy, and cost-effectiveness. Basic equipment, including a slit lamp, applanation tonometer, direct and indirect ophthalmoscopes etc., should be available for delivery of CEC. There is also an operating microscope with adequate number of instrument sets for performing any procedure. There are systems in place for the ongoing supply of consumables. Further resources vary based on the service level where eye care is delivered

• Health information: An eye health information system allows to register (systematically tracking all patients), relay (facilitate information sharing), and recall (timely review and reassessment) medical data. This permits the production, analysis, and dissemination of reliable information on eye health determinants, eye health status, and eye health system performance. An electronic medical record (EMR) / Electronic Health Record (EHR) or a manual collection of data needs to be in place
• Finance: An eye health financing system, which raises adequate funds for eye care, and ensures that patients with chronic eye conditions do not suffer from unaffordable expenses due to protracted illness and extended treatment. Appropriate health insurance-based financing methods should be available to cover the CEC costs. India is a classic example of how financing for cataract surgery has increased the CSR from 1342/million in 1995 to 3620/million in 2002, and it is continuing to do so.[ 29 ] A recently published analysis has shown that many developing countries have experienced an increase in CSR in the last years, with the greatest increase observed for Iran (from 1331/million in 2005 to 6328/million in 2011) and Argentina (from 1769/million in 2005 to 5515/million in 2011)[ 14 ]
• Governance: CEC relies on solid leadership and governance to guarantee universal eye health coverage and integration within the national health system; and to maintain strong links between government organizations, NGOs, and private local service providers. Finally, adequate advocacy is needed to increase awareness among stakeholders and ensure resources and environment for the treatment of major eye conditions.[ 30 ]

Implementation of Comprehensive Eye Care

Several solutions have been proposed so far to strengthen the different aspects of the CEC building blocks, including vertical and horizontal integration, PEC services in the community, formal and informal training to enable task shifting, and competence and funding buildup.[ 31 ] In addition, commitment from political leadership coordinated with voluntary associations, NGOs, and public–private partnerships is critical to raising adequate funding.[ 32 ]

These services at a community level have been implemented with specialist eye health outreach visits to remote settings,[ 36 ] which has been associated with more efficient care in rural African districts.[ 37 ] Moreover, the training of the mid-level and third level eye care personnel is addressed to perform comprehensive eye examination instead of disease-specific assessment (like cataract or trachoma); this has shown the potential to reduce the global burden of blindness from all causes in the long-term.[ 38 ] When focusing on a single condition, all the aspect of the disease, from screening to visual rehabilitation should be covered. The ophthalmologist and the mid-level ophthalmic personnel must work altogether as a team. Every single member of the team should have clearly defined skills and responsibilities, and they should be motivated with new career opportunities, good financial and professional rewards, and continuous professional development programs for a more efficient delivery of eye care[ 39 ]

• Service delivery: Different approaches to delivery of eye care services range from integration into the existing primary health services, to creating new models such as the rural family health system in Pakistan or the pyramidal structure of vision centres in India. A positive example of aligning national eye health strategies and low vision services with health system strengthening has been effectively provided in Pakistan[ 40 ] and by many countries in sub-Saharan Africa, where the integration of PEC services into the existing primary health services has led to an increasing access of the population to eye care initiatives throughout the continent.[ 41 , 42 ] Fruition of eye care services can be also supported by outreach activities; example is given by the Swiss Red Cross in Ghana, Togo, and Mali, where outreach consultations are conducted in areas not supplied by mid- and tertiary level eye care
• Consumables and technology: A recent study on the types of facilities caring for DR in India, the India 11-city 9-state study, has shown that positive results have been reached towards a comprehensive management of the disease, even though additional steps are needed. Technologic innovations, like teleophthalmology, non-mydriatic retinal cameras, and automated perimeters, will facilitate the referral system, enabling direct sharing of clinical information between PEC and secondary centers.[ 26 ] It has been proved that the addition of frequency doubling perimeter examination at the PEC level increases the sensitivity for glaucoma detection by 20%.[ 43 ] Teleophthalmology has been successfully used for eye screening for DR and ROP and in teaching and training new technicians performing photographs[ 25 ]
• Health information: Information systems such as electronic health records (EHRs) have been demonstrated to be useful tools in comprehensive data management. As instance, a pilot project providing computers with health information registration software and Internet connectivity via mobile phones has been set in three eye units in Kenya, offering also training for eye health personnel, at a total cost of around $3 a month. After initial reluctance, the project has been accepted, allowing easy and direct access to data and generation of medical reports.[ 41 ] Similarly, the study “Reorganizing the Approach to Diabetes through the Application of Registries” (RADAR) in Canada has been set up with the aim to combine innovative EHRs technology with national diabetes registers to deliver organized care in remote First Nations Canadian communities[ 44 ]
• Finance: The experiences of the integrated multilevel system of L V Prasad Eye Institute (LVPEI) in India has demonstrated that a CEC system can achieve financial self-sustainability, providing high-quality and low-cost eye care in rural areas with more than 50% of services free of cost.[ 8 ] Several other organizations have also demonstrated this, in other parts of India and in different countries, like Australia, sub-Saharan Africa, Middle East, and Latin America[ 45 ]
• Governance: As example of successful governance, Sri Lanka has launched from 2007 a two-phase National Program for the Prevention and Control of Avoidable Blindness (NPPCAB) thanks to the collaboration of the College of Ophthalmologists and the Ministry of Health. A Vision 2020 Secretariat was established at the Health Ministry Head Office with a dedicated and competent team for coordination of the activities, infrastructure, and human resources. The control of five major ophthalmic conditions (cataract, primary eye care and childhood blindness, glaucoma, diabetic retinopathy (DR), refractive errors, and low vision) and the implementation of control programmes in most of the districts of the country were their main tasks. A population survey for evidence-based eye care resources planning was set in place. Free cataract operations were conducted in large numbers especially in the areas affected by the war. Children were screened in the primary school for refractive errors, and free spectacles were provided across the country. PEC was incorporated into the primary health care system in 13 out of the 25 districts, and a referral system was established from the primary level to tertiary level of eye care. Finally, awareness programmes for DR[ 46 ] and glaucoma were carried out at both a national and a local level[ 47 ]

Human resource planning must be effectively supported by the knowledge of the current prevalence and future projections of ocular diseases in a given country. Epidemiologic cross-sectional surveys and rapid assessment studies are indispensable tools in the assessment of public health needs and monitoring interventions[ 48 ]

Finally, to ensure equity in eye care access, several countries have included eye services in the national health coverage schemes. Thailand, for instance, achieved universal health coverage through the implementation of the Universal Coverage Scheme, the main social health insurance program in the country, which currently covers approximately 75% (47 million people) of the entire population. Some successful factors of Thailand's universal health care system have been a strong political leadership, community engagement, and stiff budget control.[ 49 ] In the same period, Ghana has established a National Health Insurance Scheme in 2003, including cataract and eyelid surgery, biometry, visual fields, refraction, and basic ophthalmic preparations, which nowadays covers more than 60% of the population.[ 50 ] Burkina Faso has introduced user fees waivers for public eye care facilities for children under five, with a six-fold increase in the number of children attending at health facilities.[ 51 ] In Chile, where 70% of the population is not covered by private insurance, the government guarantees universal eye health coverage by paying the fees in full if the patients unable to afford. In India, the Pradhan Mantri Jan Arogya Yojana (PMJAY) or National Health Protection Scheme has been launched in 2018 providing interventions in primary, secondary, and tertiary care, including eye care, covering both preventive, therapeutic, and promotive actions.[ 52 ] Finally, Saudi Arabia has incorporated prevention of blindness into its new primary health care policy with a dedicated budget line and training schedule.[ 53 ]

Issues and Challenges in Providing CEC

Data from several population-based surveys and from the IAPB country chairs regarding the national health policy, the national health expenditure, the insurance systems, the expenses for eye health care, the strength of eye health personnel, the training programmes, human resources planning, and the presence of the international NGOs in different Asian countries in 2015 have been published.[ 54 ] The eye care service profile in the Southeast Asia region turned out to be encouraging: the blindness prevalence was low in Bhutan (0.33%), Nepal (0.35%), Myanmar (0.58%) and Thailand (0.59%), but still high in Timor-Leste (4.2% for people over 40). Five out of the 11 countries analyzed have an established national eye health plan, namely Bangladesh, with the Bangladesh National Control of the Blind (BNCB); India, with the National Program for Control of Blindness (NPCB); Indonesia, with the Ministry of Health, National Eye Committee; Nepal, with the Apex Body of eye health; and Thailand, with the National Committee of Eye Care services. Free primary eye care delivery is still not uniform and eye health care insurance coverage is highest in Thailand, compared to the other countries. As per capacity and resource building, the number of ophthalmologists has been increasing since 2010, even though the availability of auxiliary ophthalmic personnel is still insufficient. Cataract surgery coverage is as high as 96% in certain countries, including Thailand, Sri Lanka, and Nepal. Finally, strong links between international NGOs and eye care provision is established in many countries, including Bangladesh, India, Nepal, Indonesia, and Timor Leste.

Despite efforts at global, regional, country, and district levels in terms of political and financial commitment, most of the LMICs in the rest of the World have still unmet needs and insufficient budgets for health care. Shortage of eye care human resources, lack of educational skills, paucity of funds, limited access to instrumentation and treatment modalities, poor outreach, lack of transportation, and fear of surgery may still represent the major barriers to CEC large-scale diffusion.[ 53 ] Each of the requirements listed above needed for health system strengthening represents a serious issue for LMICs, due to consistent political, economic, and logistic barriers. The issues in providing CEC can be assessed with the same combination of the WHO six building blocks proposed above:

• Human resources: Consistent gaps in the medical coverage characterize LMICs, though there are more than 200,000 eye care practitioners in the World.[ 55 ] A recent study has shown that only five countries in sub-Saharan Africa, out of 21 included in the review, are currently meeting WHO standards for ophthalmic personnel, and that is not expected to change by 2020;[ 56 ] the rest of the 21 countries had fewer ophthalmologists than recommended (i.e. four per one million), while no country in sub-Saharan Africa had the appropriate number of optometrists.[ 57 ] Inappropriate human resources coupled with inadequate level of technology and lack of equipment and medications have been identified as the major causes of low CSR and trichiasis surgery[ 58 , 59 ]
• Service delivery: For eye care especially, population coverage is inadequate, and treatment resources are unevenly distributed. Along with international differences, local inequities should be addressed to fulfill universal coverage of the CEC system. Social, economic, and demographic factors, such as age, gender, place of residence (state or district), personal incomes, ethnicity, political and health status, also reduce the potential of success of any intervention.[ 53 ] As a result, a large percentage of “neglected population” receive very little health care of appropriate quality.[ 12 , 60 ] Neglected population constitutes people living in urban slums or rural and tribal areas, illiterates from lower socioeconomic groups, women and children, people with disabilities, and migrants and refugees[ 61 ]
• Consumables and technology: Service delivery, including transportation to care centers, distribution logistics, surgical consumables and technology, and dispensing treatment represent the main challenges in establishing CEC systems. Outreach camps usually help in filling these gaps, but this approach is often not sufficient to cover all the needs of the population, especially in the poor and rural areas. Equipment maintenance should also be planned to provide quality services efficiently and effectively. A questionnaire on the key issues and challenges faced by eye health providers with regard to eye care equipment published in 2010 revealed that 60% of government eye units had equipment that did not work and 20% of all the eye units reported that they had equipment left unrepaired for more than 12 months.[ 62 ] The impact of breakdowns resulted in frustrating delay in proper treatment and referral. In addition, the inability to conduct a proper assessment (due to non-functioning instrumentation) increases the risk of disease progression and poor outcomes
• Health information: Medical record systems are often lacking, resulting in fragmented healthcare data; if such systems are in place, there is no review or feedback on the information collected to make evidence-based decisions. At the same time, the quality of the records may also be questionable
• Finance and Governance: Growing evidence shows that early diagnosis and treatment of many chronic diseases can significantly modify their natural history.[ 63 , 64 , 65 ] Only a few countries have planned for defined public health approaches in terms of awareness, health education, and prevention. Screening programmes have been proposed for DR,[ 66 ] AMD,[ 67 ] glaucoma,[ 68 ] refractive errors in children,[ 69 ] and ROP.[ 70 ] However, there is a severe limitation of access and affordability in most parts of the World.[ 71 , 72 ] Advocacy is needed to encourage governments to set up training programmes, professional standards, careers and salaries for ophthalmic workers; however, only ophthalmologists, ophthalmic nurses, optometrists, opticians, and orthoptists are currently recognized in the International Standard Classification of Occupations (ISCO-08). Recognition of new figures of eye care allied personnel is necessary to ensure to address the lacks and inequality in service delivery.

Apart from these major themes, there are issues with compliance to treatment, especially for chronic conditions as well as having a robust two-way referral mechanism in place. In most LMICs, PEC services are defective and inadequately integrated into primary health care and national health systems.[ 73 ] A recent analysis in two districts in Tanzania has shown that despite successful and satisfying training of primary health workers in primary eye care, there was still a strong limitation in service provision and fruition by the population due to poor integration in the local health system. Major flaws recognized were absence of an agreed and defined system of supervision of the trained workers; inability of the health management information system to collect information on a full spectrum of eye conditions treated in primary facilities; inadequateness of the referral systems to ensure continuity of care between primary and secondary level facilities; and excessive costs for many patients to uptake the referral. As a result, many primary health workers felt abandoned, frustrated, and demotivated in providing eye care.[ 74 ]

The referral organization is also poor. This leads to delay in treatment, increase in the possibility of self-medication, approaching pharmacies directly or using traditional remedies, or the compulsion to seek primary care directly at secondary and tertiary levels, using resources required for more complex cases.[ 75 ] Finally, coverage by low vision programs is often inadequate with respect to the demand. In LMICs, it is estimated that only 5–10% of the people needing low vision services have access to it.[ 76 ] Finally, it must be kept in mind that many LMICs still have to tackle infectious diseases, such as trachoma and onchocerciasis, as well as cataract and uncorrected refractive errors, along with rapidly emerging NCEDs.

In conclusion, while a vertical model of eye care has been working efficiently for diseases like onchocerciasis, trachoma, and cataract, a comprehensive eye care approach should be advocated whenever possible to address the rapidly growing burden of NCEDs. Developing a robust, sustainable, and good-quality CEC system throughout the world, with focus on areas of the highest need, is the first step toward eliminating avoidable blindness. Strengthening the components of health system would be the approach as we move forward.

The recognition of new figures of eye care personnel is necessary to address the shortage in human resources and service delivery. Involvement of primary health workers, clinical officers, and non-ophthalmic personnel help in assuring eye health continuity and service delivery. For appropriate delivery of eye care services, integration into the existing primary health services is pivotal. Modern technologies and standardized data collection tools are necessary, but also need an even distribution, initial training, and regular maintenance services. Advocacy and recognition of new figures of eye care allied personnel is necessary to ensure to address the lacks and inequalities in service delivery and to persuade governance to invest in eye care. Moreover, CEC should be necessarily integrated in the health system of each country. The specific approach, the composition of personnel teams, and the territorial organization of CEC services should be tailored according to the specific disease/socioeconomical context/demographical setting. Other, but not less important, concerns relate to the proper development of rehabilitation services for the irreversible visually impaired. Further work is needed to implement these programmes both in the central and the peripheral centers.

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Current Topics in Eye Research

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

This series continues to present basic research topics to the ophthalmic community. Some of the chapters are difficult reading for anyone not well grounded in biochemistry or molecular biology. The article most pertinent to clinical ophthalmology is by Ronald A. Laing of Boston University on specular microscopy of the cornea. The chapter by Eugene Copeland of Woods Hole, Mass, on the eyes of fish is also fascinating reading. Who would have thought only ten years ago that the oxygen tension in the retinal area of fish is ten times that of the blood in other organs (the swim bladder excepted). The chapter on accommodation in vertebrates by J. G. Sivak of Waterloo, Ontario, is as complete a survey as you can hope for.

Blodi FC. Current Topics in Eye Research. Arch Ophthalmol. 1980;98(12):2248. doi:10.1001/archopht.1980.01020041100038

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September 2021

Latest Innovations and Future Directions in Optometry

From myopia control to IOLs, new technologies keep coming down the pike.

Jaclyn Garlich, OD, FAAO

Roya Habibi, OD, FAAO, FSLS

Jacob Lang, OD, FAAO, Dipl ABO

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At A Glance

• New multifocal contact lens and spectacle technologies are additions to the more traditional methods available to address the worldwide growth in the prevalence of myopia.
• New topical drops, both prescription and over the counter, add to the optometric therapeutic arsenal.
• A recently approved systemic drug may change management patterns for thyroid eye disease.

We are seeing an exponential surge in new trends, technologies, and treatments in optometry and hope to inspire some further research by giving you a high-level introduction to some of the up-and-comers in eye care.

MYOPIA CONTROL

Myopia is an age-old topic, but what is new is the growing prevalence of myopia worldwide. In 2000, the prevalence of myopia in the world population was estimated to be 22.9%, and that figure is projected to rise to 49.8% by 2050. 1 There are multiple theories as to the cause of this growth, including increasing screen time and decreasing time spent outdoors among young people. Luckily, our evidenced-based and validated treatment options for myopia control are also steadily increasing.

Soft Contact Lenses

In 2020, the FDA approved MiSight 1 day (CooperVision) lenses (Figure 1), making them the first daily disposable soft contact lenses labeled for slowing the progression of myopia. Clinical studies found that MiSight 1 day lenses provided a 59% reduction in myopia progression in comparison with a single-vision 1-day lens, as measured by spherical equivalent, and a 52% reduction in mean axial elongation. 2

Click to view larger

Figure 1. The ActivControl technology in MiSight 1 day lenses uses an optic zone concentric ring design with alternating vision correction zones and treatment zones. Two zones are vision correction zones with the label power of the contact lens, and the alternating two zones are treatment zones with 2.00 D of defocus to slow the progression of myopia. (Image courtesy of CooperVision.)

Gas Permeable Contact Lenses

Orthokeratology (ortho-k) has been used at least since the 1960s in the management of myopia. The first rigid gas permeable lens for ortho-k, Paragon CRT (CooperVision Specialty EyeCare), received FDA approval in 2002, 3 and products and options have continued to grow since then. In May of this year, Johnson & Johnson Vision announced FDA approval of its Acuvue Abiliti Overnight Therapeutic Lenses for the management of myopia. 4 That same month, CooperVision announced that its Procornea DreamLite night lenses for ortho-k had received the CE Mark from European regulators for slowing the progression of myopia in children and young adults. 5 CooperVision also announced this year that it has begun offering 5-mm customization of the back optic zone diameter for increased efficacy for its Paragon CRT and CRT Dual-Axis lenses in myopia management strategies. 6

Many doctors have been prescribing atropine off-label for myopia control. Vyluma, a newly formed subsidiary of Nevakar, announced in May that the phase 3 CHAMP trial of its pharmaceutical atropine eye drop NVK002 is in late stages in the United States and Europe. 7 The drop has the potential to be an FDA-approved pharmacologic method for myopia control, the company suggested.

Spectacle Correction

Glasses don’t work for myopia control, right? Perhaps it’s time to think again.

Essilor announced in May that it has been granted breakthrough device designation by the FDA for its Stellest spectacle lens to correct and slow the progression of myopia. 8 Data from a pivotal clinical trial presented at this year’s Association for Research in Vision and Ophthalmology meeting demonstrated that, at 2 years follow-up, Essilor’s highly aspheric lenslet target (HALT) technology, worn at least 12 hours per day, slowed myopia progression by 67% in comparison with single-vision lens wear. After 1 year in the ongoing 3-year trial, eye growth in children wearing the Stellest lenses was similar to or slower than that in nonmyopic children, according to Essilor. 9

Also in May, researchers at Hoya and the Centre for Myopia Research in Hong Kong published follow-up data on the company’s MiyoSmart spectacle lenses with patented defocus incorporated multiple segments (DIMS) technology, showing that wearing the DIMS lens slowed the progression of myopia by 52% and axial length growth by 62% at 2 years in comparison with single-vision lens wear. 10

CONTACT LENSES

In addition to the contact lenses for myopia control discussed above, a number of new conventional contact lens models have come to the market recently.

The silicone hydrogel material of the daily disposable Bausch + Lomb Infuse lens (Bausch + Lomb; Figure 2) is infused with a proprietary combination of ingredients designed to promote comfort, inspired by the Tear Film and Ocular Surface Society’s DEWS II report, according to the company. 11 The infused ingredients include osmoprotectants and electrolytes to help maintain ocular surface homeostasis and moisturizers to help retain hydration and maintain tear proteins in a healthy state, the company states.

Figure 2. The Bausch + Lomb Infuse contact lens, a silicone hydrogel daily disposable, helps to address contact lens dryness, according to the company. (Image courtesy of Bausch + Lomb.)

Alcon added cylinder correction to its Precision1 one-day contact lenses for its toric Precision1 for Astigmatism line (Alcon). The lens settles in less than 60 seconds within 3° of ideal orientation and has a 99% first-fit success rate, according to the company. 12

Johnson & Johnson Vision introduced an upgrade to its Acuvue Oasys Multifocal Lens , now including a Pupil Optimized Design. The new design optimizes parameters for patient age and refraction, according to the company, improving performance and comfort. 13

We also now have a large selection of options for our astigmatic presbyopic patients, with Biofinity toric and Biofinity XR toric lenses (CooperVision) 14 and Bausch + Lomb Ultra Multifocal for Astigmatism lenses. 15

There are several innovations in the development pipeline aiming to use contact lens technology as a platform to achieve goals such as monitoring IOP, 16 displaying augmented reality, 17 and fostering corneal wound healing. 18

The high-concept contact lens technology that may be closest to reaching the US market is an antiallergy drug-eluting lens being developed by Johnson & Johnson Vision. Acuvue Theravision with Ketotifen (Figure 3)releases an H1 histamine receptor antagonist to reduce itching due to allergies and improve lens comfort. The device has received regulatory approval in Japan and Canada. 19

Figure 3. Acuvue Theravision with Ketotifen is a medication-releasing contact lens for patients in Japan and Canada who need vision correction and itchy eye relief. (Image courtesy of Johnson & Johnson Vision.)

We are lucky to be in a profession where there is continual innovation to allow us to better treat our patients. Let’s look at a few new eye drops—in addition to the myopia control drops discussed above—that have expanded our arsenal in the past 2 years.

In June, Santen received FDA approval for its formulation of cyclosporine 0.1% ophthalmic emulsion (Verkazia) for the treatment of vernal keratoconjunctivitis (VKC) in children and adults. 20 The formulation’s oil-in-water cationic emulsion provides improved ocular bioavailability of cyclosporine, according to the company. It works by inhibiting T-cell activation, which controls allergic response and inflammation. The drops can be used over a sustained period of time, which means that steroids can be reduced. Recommended dosage is four times daily, and the product is approved for use in children as young as 4 years.

The FDA approved loteprednol etabonate ophthalmic suspension 0.25% ( Eysuvis , Kala Pharmaceuticals) for the short-term treatment of the signs and symptoms of dry eye disease in October 2020. 21 It became the first ocular corticosteroid approved specifically for the treatment of dry eye disease and the first approved specifically for short-term (up to 2 weeks) treatment of the signs and symptoms of dry eye disease. The drop, dosed four times daily, uses the company’s proprietary mucus-penetrating particle drug delivery technology (Ampplify) to enhance bioavailability of the active ingredient at the target site, according to Kala.

Also approved last year was oxymetazoline HCl ophthalmic solution 0.1% ( Upneeq , RVL Pharmaceuticals), indicated for patients with acquired blepharoptosis who do not want to pursue surgical repair. 22 In two phase 3 trials, patients who received the drug once daily experienced statistically significant improvement in visual field compared to a placebo group (Figure 4). The drop is the only FDA-approved medical treatment for ptosis.

Figure 4. Examples of positive results after a first dose of oxymetazoline for blepharoptosis. (Image courtesy of RVL Pharmaceuticals.)

Itching for more over-the-counter (OTC) allergy drops? Alcon’s suite of products containing olopatadine is now available OTC: Pataday Once Daily Relief Extra Strength (formerly Pazeo), Pataday Once Daily Relief (formerly Pataday), and Pataday Twice Daily Relief (formerly Patanol). 23 Further expanding the shelf, in September 2020 the FDA approved ketotifen fumarate ophthalmic solution 0.035% antihistamine ( Alaway Preservative Free , Bausch + Lomb), which became the first OTC preservative-free eye drop formulation approved to relieve symptoms of allergy. 24

Reproxalap ophthalmic solution 0.25% (Aldeyra Therapeutics) is a RASP inhibitor, which could be the next category of antiinflammatory medications in eye care. 25-27 It targets early, upstream proinflammatory signaling cascades and is showing promise in several ocular conditions such as dry eye, allergic conjunctivitis, and uveitis.

SYSTEMIC DRUG

In January 2020, teprotumumab-trbw ( Tepezza , Horizon Therapeutics) became the first drug FDA-approved for the treatment of thyroid eye disease (TED). 28 Teprotumumab is a fully human monoclonal antibody and a targeted inhibitor of the insulin-like growth factor-1 receptor. In a phase 3 clinical trial, teprotumumab was shown to improve proptosis, diplopia, and quality of life in patients with TED. 29 This finding puts to rest the watch-and-wait mentality traditionally applied to patients with TED.

There may also be applications for this new drug in patients with long-standing, chronic TED. 30 This is an excellent example of a situation in which optometry must have an open mind to incorporate new therapeutics. It is crucial that we stay ever-vigilant to detecting ocular conditions early in the disease state, knowing that we are in many cases the gate-keepers and primary care physicians of eye care.

PRESBYOPIA DROPS … SOON?

The race for an FDA approval of a topical presbyopia treatment is on, and Allergan appears to be in the lead. The company in February submitted a new drug application to the FDA for its investigational eye drop, AGN-190584, for the treatment of presbyopia, and the FDA is expected to act on the application by the end of this year. 31 The drop is an optimized formulation of pilocarpine 1.25% delivered in a proprietary vehicle. It is administered once daily, and the proposed mechanism of action is through contraction of the iris sphincter muscle to enhance depth of focus and improve near and intermediate visual acuity while maintaining some pupillary response to light. AGN-190584 also contracts the ciliary muscle to facilitate accommodation, according to the company.

But Allergan is not alone. Many companies are in hot pursuit of their own presbyopia treatment drops. Others rising to the challenge include: Eyenovia, Novartis Pharmaceuticals, Ocuphire Pharma, Orasis Pharmaceuticals, OSRX Pharmaceuticals, Lenz Therapeutics (formerly Presbyopia Therapies), and Visus Therapeutics. For a recent review, see “ Answering the Call of Presbyopic Patients ” by Selina R. McGee, OD, FAAO, and Melissa Barnett, OD, FAAO, FSLS, FBCLA, from the January/February 2021 issue of Modern Optometry .

Cataract surgery is increasingly becoming an opportunity to enhance patients’ vision and treat other ocular pathologies. Multifocal IOL technologies continue to evolve and improve with new options to match the visual demands of patients. The biggest trend seems to be toward lenses that provide improvement at intermediate distances but not enough power for clear vision at the typical near working distance. By giving up the hard near focus of more traditional multifocal IOLs, it appears that these extended range of vision lenses can avoid some of the glare and halos occasionally experienced with full-range multifocal options.

The Acrysof IQ Vivity (Alcon; Figure 5), introduced in January and described by the company not as a multifocal but rather as a “nondiffractive extended depth of focus IOL,” is an example of this type of lens option. In clinical trials of the lens, 94% of patients reported having good or very good vision at distance, and 92% reported having good or very good vision at arm’s length. Starbursts, halos, and glare were comparable to those experienced with a monofocal lens. 32

Figure 5. The AcrySof IQ Vivity IOL uses Alcon’s proprietary non-diffractive X-Wave technology to stretch and shift light without splitting it. (Image courtesy of Alcon.)

A novel implantable technology that may indicate the shape of things to come is the R-TASC smart active IOL (Swiss Advanced Vision; Figure 6). If this development program comes to fruition, it could produce the world’s first active electronic IOL implant. The company’s aim is to develop a smart, real-time autofocus, solar-powered, multifocal IOL. The autofocus system would detect the distance of objects and trigger the transfer of liquid in or out of the lens optic, modifying the power of the IOL. The company’s website gives no indication of the phase of development. 33

Figure 6. The high-concept R-TASC IOL would be equipped with an autofocus system that detects the distance of objects. (Image courtesy of Swiss Advanced Vision.)

A PROFESSION RIPE WITH INNOVATION

With the products discussed here and additional releases sure to come in the near future, we have many new treatments and technologies to offer our patients, and we can look forward to more. Look for information in upcoming issues of Modern Optometry to help you embrace this bright future.

• 1. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology . 2016;123(5):1036-1042.
• 2. Our products. MiSight 1 day. CooperVision. coopervision.com/practitioner/our-products/misight-1-day/misight-1-day. Accessed August 4, 2021.
• 3. Premarket Approval. Paragon CRT. Food and Drug Administration. June 13, 2002. www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P870024S043. Accessed August 5, 2021.
• 4. Johnson & Johnson Vision announces FDA approval of Acuvue Abiliti Overnight Therapeutic Lenses for myopia management. Eyewire News. May 12, 2021. eyewire.news/articles/johnson-johnson-vision-announces-fda-approval-of-acuvue-abiliti-overnight-therapeutic-lenses-for-myopia-management/. Accessed August 5, 2021.
• 5. CooperVision DreamLite® Ortho-K lenses gain European approval for slowing progression of myopia [press release]. CooperVision Specialty EyeCare. May 25, 2021. coopervision.com/our-company/news-center/press-release/coopervision-dreamlite-ortho-k-lenses-gain-european-approval. Accessed August 5, 2021.
• 6. CooperVision Specialty EyeCare announces 5 mm BOZD customization for Paragon CRT® and CRT Dual Axis® Lenses [press release]. CooperVision Specialty EyeCare. January 19, 2021. coopervision.com/our-company/news-center/press-release/coopervision-specialty-eyecare-announces-5-mm-bozd. Accessed August 5, 2021.
• 7. Vyluma Inc. launches with robust ophthalmic portfolio, leading with a pharmaceutical treatment in phase III for myopia [press release]. Vyluma. May 25, 2021. vyluma.com/press_release/vyluma-inc-launches-with-robust-ophthalmic-portfolio-leading-with-a-pharmaceutical-treatment-in-phase-iii-for-myopia/. Accessed August 5, 2021.
• 8. Essilor receives FDA “breakthrough device” designation for Essilor Stellest, its new generation of spectacle lens solutions in the fight against myopia [press release]. Essilor. May 17, 2021. www.essilor.com/en/medias/press-releases/essilor-receives-fda-breakthrough-device-designation-for-essilor-stellest-its-new-generation-of-spectacle-lens-solutions-in-the-fight-against-myopia/. Accessed August 5, 2021.
• 9. New results on Essilor Stellest lens to be presented at the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO 2021) [press release]. Essilor. April 4, 2021. www.essilor.com/en/medias/press-releases/new-results-on-essilor-stellest-lens-to-be-presented-at-the-annual-meeting-of-the-association-for-research-in-vision-and-ophthalmology-arvo-2021/. Accessed August 5, 2021.
• 10. Lam CSY, Tang WC, Tse DY, et al. Defocus incorporated multiple segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br J Ophthalmol . 2020;104(3):363-368.
• 11. Bausch + Lomb Infuse. www.bauschinfuse.com/ecp/. Accessed August 5, 2021.
• 12. MyAlcon Professionals. Precision1 for Astigmatism. professional.myalcon.com/contact-lenses/daily/precision-astigmatism/. Accessed August 5, 2021.
• 13. Acuvue Oasys Multifocal With Pupil Optimized Design. Johnson & Johnson Vision. www.jnjvisionpro.com/products/acuvue-oasys-multifocal#product_information. Accessed August 5, 2021.
• 14. Biofinity toric and Biofinity XR toric. CooperVision. coopervision.com/practitioner/our-products/biofinity-family/biofinity-toric-biofinity-xr-toric. Accessed August 5, 2021.
• 15. Bausch + Lomb Ultra contact lenses. Bausch + Lomb. www.expectultracomfort.com/ecp/lens-parameters. Accessed August 5, 2021.
• 16. Smart contact lenses have potential to monitor, treat glaucoma. Cleveland Clinic. Consult QD. September 9, 2020. consultqd.clevelandclinic.org/smart-contact-lenses-have-potential-to-monitor-treat-glaucoma/. Accessed August 5, 2021.
• 17. AR contact lens wins CES’ Last Gadget Standing competition. Las Vegas Review-Journal. January 12, 2021. www.reviewjournal.com/business/conventions/ces/ar-contact-lens-wins-ces-last-gadget-standing-competition-2251189/. Accessed August 5, 2021.
• 18. UNH researchers create a hydrogel contact lens to treat serious eye disease. University of New Hampshire Newsroom. March 12, 2019. www.unh.edu/unhtoday/news/release/2019/03/12/unh-researchers-create-hydrogel-contact-lens-treat-serious-eye-disease. Accessed August 5, 2021.
• 19. Johnson & Johnson Vision receives approval in Canada for first drug-releasing contact lens for vision correction and allergic eye itch. Eyewire News. April 27, 2021. eyewire.news/articles/johnson-johnson-vision-receives-approval-in-canada-for-first-drug-releasing-contact-lens-for-vision-correction-and-allergic-eye-itch/. Accessed August 5, 2021.
• 20. Santen receives FDA approval for Verkazia (cyclosporine ophthalmic emulsion) 0.1% for the treatment of vernal keratoconjunctivitis in children and adults [press release]. Santen. June 24, 2021. www.businesswire.com/news/home/20210624005365/en/Santen-Receives-FDA-Approval-for-Verkazia%E2%84%A2-Cyclosporine-Ophthalmic-Emulsion-0.1-for-the-Treatment-of-Vernal-Keratoconjunctivitis-in-Children-and-Adults. Accessed August 5, 2021.
• 21. Kala Pharmaceuticals receives FDA approval of dry eye disease treatment Eysuvis. Eyewire News. October 20, 2020. eyewire.news/articles/kala-pharmaceuticals-announces-fda-approval-of-dry-eye-disease-treatment-eysuvis/#:~:text=The%20FDA%20on%20Tuesday%20approved,symptoms%20of%20dry%20eye%20disease. Accessed August 5, 2021.
• 22. Osmotica Pharmaceuticals plc receives FDA approval for Upneeq (oxymetazoline hydrochloride ophthalmic solution), 0.1% for acquired blepharoptosis (droopy eyelid) in adults [press release]. Osmotica Pharmaceuticals. July 9, 2020. ir.osmotica.com/news-releases/news-release-details/osmotica-pharmaceuticals-plc-receives-fda-approval-upneeqtm. Accessed August 5, 2021.
• 23. Pataday Once Daily Relief Extra Strength. Now available without a prescription. MyAlconProfessionals. https://professional.myalcon.com/eye-care/ocular-allergies/pataday/. Accessed August 5, 2021.
• 24. FDA approves Bausch + Lomb Alaway Preservative Free OTC drops. Eyewire News. September 25, 2020. eyewire.news/articles/fda-approves-bausch-lomb-alaway-preservative-free-ophthalmic-solution/. Accessed August 5, 2021.
• 25. Mandell KJ, Clark D, Chu DS, Foster CS, Sheppard J, Brady TC. Randomized phase 2 trial of reproxalap, a novel reactive aldehyde species inhibitor, in patients with noninfectious naterior uveitis: model for corticosteroid replacement. J Ocul Pharmacol Ther . 2020;36(10):732-739.
• 26. Clark D, Cavanagh B, Shields AL, Karpecki P, Sheppard J, Brady TC. Clinically relevant activity of the novel RASP inhibitor reproxalap in allergic conjunctivitis: the phase 3 ALLEVIATE trial. Am J Ophthalmol . 2021;230:60-67.
• 27. Clark D, Tauber J, Shepard J, Brady TC. Early onset and broad activity of reproxalap in a randomized, double-masked, vehicle-controlled phase 2b trial in dry eye disease. Am J Ophthalmol . 2021;226:22-31.
• 28. FDA approves first treatment for thyroid eye disease [press release]. Food and Drug Administration. January 21, 2020. www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-thyroid-eye-disease. Accessed August 5, 2021.
• 29. Douglas RS, Kahaly GJ, Patel A, et al. Teprotumumab for the treatment of active thyroid eye disease. N Engl J Med . 2020;382(4):341-352.
• 30. Ozzello DJ, Kikkawa DO, Korn BS. Early experience with teprotumumab for chronic thyroid eye disease. Am J Ophthalmol Case Rep . 2020;19:100744. Published 2020 May 15.
• 31. Allergan, an AbbVie Company, submits new drug application for investigational AGN-190584 for the treatment of presbyopia [press release]. Allergan. February 25, 2021. news.abbvie.com/news/press-releases/allergan-an-abbvie-company-submits-new-drug-application-for-investigational-agn-190584-for-treatment-presbyopia.htm. Accessed August 5, 2021.
• 32. Alcon announces launch of AcrySof IQ Vivity, the first and only non-diffractive extended depth of focus intraocular lens in the U.S [press release]. Alcon. January 7, 2021. www.alcon.com/media-release/alcon-announces-launch-acrysof-iq-vivity-first-and-only-non-diffractive-extended. Accessed August 9, 2021.
• 33. R-TASC Smart Active Intraocular Lens for Cataract Surgery. Swiss Advanced Vision Intraocular Lens. sav-iol.com/r-tasc/. Accessed August 9, 2021.

Owner, Envision Optometry, Boston Editor and Founder, 20/20 Glance Member, Modern Optometry Editorial Advisory Board [email protected]; Instagram: @2020glance, @envisionboston Financial disclosure: Speaker/Advisor (Allergan, Dompe, Novartis Pharmaceuticals, Orasis Pharmaceuticals, Tarsus, Zeiss)

Associate Optometrist, Eye Associates Northwest, Seattle [email protected]; Instagram: @rnhabibi Financial disclosure: None

Lead Optometrist, Associated Eye Care, Stillwater, Minnesota Member, Modern Optometry Editorial Advisory Board [email protected]; Instagram: @seeoneteachone Financial disclosure: Speaker/Advisor (Allergan, Avellino, Horizon Therapeutics, Novartis Pharmaceuticals, Orasis Pharmaceuticals, Scope Eyecare, Sun Pharma, AOS)

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Research Topics

The Department of Ophthalmology and Visual Sciences offers medical students and residents a variety of research opportunities. Please browse the basic science, translational and clinical research projects currently underway below.

Research Topic: Corneal endothelial health judged by endothelial image analysis

Description.

Endothelium is critical for dehydrating the cornea and keeping it clear. With loss of its barrier and pump function, the cornea swells and corneal transplantation may be needed.

Changes in the number, shape and size of the cells may predict loss of function.

Key Research Question/Hypothesis 

Effect of drugs, surgery, devices, and preservation media on the endothelium.

Images of the endothelium captured with either a specular or confocal microscope that can take repeated pictures of the endothelial cells non-invasively in patients. Once images are captured, they can be analyzed with special software in the Cornea Image Analysis Reading Center (CIARC) of the Department.

Student learn these techniques working with both patients and technicians, depending on the project.

Ongoing projects.

Status of IRB/IACUC approval

Image analysis studies in CIARC approved; ongoing projects have IRB approval. If launching a new project, IRB approval will need to be obtained.

Prospects for Publishing and Presenting

Excellent; we have a long track record of publications in major journals and presentations at national and international conferences.

Contact Information

Tanisha Rankins

Secretary to Dr. Jonathan Lass

• Email:  [email protected]  
• Phone: 216.983.5164

Research Topic: Retinopathy of Prematurity and other Pediatric Studies

Effect of low birth weight on the eye’s development.

Data analysis, chart review.

Several ongoing projects—long-term data collection.

Current study has IRB approval. Any new studies will need IRB approval.

Excellent; the data base study has been presented at ARVO and is in preparation for publication in a major pediatric journal.

Dr. Faruk Orge

• Email:  [email protected]
• Phone: 440.684.1743

Research Topic: Cholesterol and function of the retina

Cholesterol is essential for life in mammal. Yet, if it is chronically in excess, it is a risk factor for cardiovascular and Alzheimer's disease and likely age-related macular degeneration.

To delineate the putative link between cholesterol and age-related macular degeneration.

Characterization of retinal function of mice deficient in different enzymes involved in cholesterol elimination. Animals are assessed by optical coherence tomography, electroretinography, fluorescein angiography and optomotor response.

Students learn these techniques working with post-doctoral researchers responsible for these projects.

All studies are approved by the IACUC.

Dr. Irina Pikuleva

• Email:  [email protected]
• Phone: 216.368.3823

Research Topic: Contact Lens Related Complications

Ongoing clinical trials related to corneal infiltrative events associated with daily or extended wear of soft contact lenses. Fungal and bacterial biofilm-contact lens models and susceptibility to contact lens care products.

Assessment of sub-clinical corneal inflammation with confocal microscopy. Assessment of bacterial endotoxin and relationship to infiltrative events with soft lenses.

• Ocular and lens cultures for assessment of bioburden
• Reading/Assessment of stored confocal images
• Collection of worn lenses for biofilm formation
• Lab Assays (in conjunction with Dr. Pearlman’s lab) for endotoxin on lens surfaces or within solution

Active approved IRB protocols exist for current clinical trials on infiltrative events, biofilm studies, and assays of previously collected lenses, tears and images.

Excellent chance for authorship on investigator initiated studies of biofilm and endotoxin assays. Listing of authors will follow standard publishing guidelines. 

Other corporate-funded work may or may not allow authorship.

Dr. Loretta Szcztoka-Flynn

• Email:  [email protected]

Research Topic: Mechanisms of retinal degenerations

How do mutations in the light receptor rhodopsin cause retinal degenerations like retinitis pigmentosa? How does the retina protect against oxidative stresses that can lead to retinal degenerations such as retinitis pigmentosa and age-related macular degeneration?

A multi-disciplinary approach is employed that includes biochemistry, molecular biology, animal models and biophysics.

All animal studies have approved IACUC protocols.

Excellent with track record of publications in major journals and presentations at national and international conferences.

Information about the laboratory can be found by browsing the Park Lab webpage.

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Shaping the Future of Eye Care

Fifteen Bascom Palmer doctors were named to The Power List, a prestigious honor celebrating impact and excellence in ophthalmology.

Fifteen Bascom Palmer Eye Institute physicians were selected for The Power List, a prestigious selection of the world’s 100 most influential people shaping the future of eye care, as published by The Ophthalmologist magazine.

“Congratulations to Bascom Palmer Eye Institute physicians for receiving this exceptional honor,” said Henri R. Ford, M.D., M.H.A., dean and chief academic officer of the University of Miami Miller School of Medicine. “We are extremely honored that 15 Bascom Palmer doctors were selected for their exceptional contributions and influence in the field. From cutting-edge treatments to groundbreaking research, these doctors are pushing boundaries and setting new standards in ophthalmology.”

Bascom Palmer’s 2024 Power List Recipients

Eduardo Alfonso, M.D.

An internationally recognized expert on ocular infectious diseases, Dr. Alfonso is recognized globally as a leader in health care administration. Dr. Alfonso has been the director of Bascom Palmer since 2007. Each year under his leadership, Bascom Palmer has been ranked the No. 1 eye hospital in the United States. The Kathleen and Stanley J. Glaser Chair in Ophthalmology, he was also named to the 2014, 2016, 2018, 2022 and 2023 Power Lists.

Hilda Capó, M.D.

The John T. Flynn Chair in Ophthalmology, Dr. Capó specializes in pediatric ophthalmology and adult strabismus. She is world-renowned for her expertise in strabismus and adjustable sutures and a pioneer in identifying the anesthetic agent’s role in the onset of double vision after cataract surgery. She has trained more than 175 residents and fellows. Dr. Capó was also named to the 2021 and 2023 Power Lists.

Janet Davis, M.D.

An internationally recognized expert in uveitis and a medical retina and vitreoretinal specialist, Dr. Davis is the Leach Chair in Ophthalmology. Her expertise includes infectious and inflammatory eye diseases. For the past seven years, she has led a Bascom Palmer surgical team that has performed more than 100 sub-retinal gene therapy procedures for inherited retinal diseases such as retinitis pigmentosa and choroideremia. Dr. Davis was also named to the 2021 and 2023 Power Lists.

Kendall Donaldson, M.D.

The Kolokotrones Chair in Ophthalmology, Dr. Donaldson is a cornea specialist whose primary research interests are cataract surgery, particularly laser-assisted cataract surgery, and severe ocular surface disease. Each year, she presents more than 100 local, national and international lectures and has authored peer-reviewed and non-peer-reviewed articles and book chapters. She was also named to the 2021, 2022 and 2023 Power Lists.

Harry Flynn, Jr., M.D.

Dr. Flynn has a long and distinguished career in academic medicine through teaching, research and patient care. A specialist in the medical and surgical treatment of diseases of the retina and vitreous, he has trained more than 600 residents, fellows and visiting physicians. Dr. Flynn is the J. Donald M. Gass Chair in Ophthalmology and unmatched as an advocate and communicator in the field. He was also named to the 2018, 2022 and 2023 Power Lists.

Anat Galor, M.D., MSPH

Dr. Galor is an expert on ocular surface pain and dry eye and its relationship with neuropathic ocular pain. She is also an expert in the epidemiology and treatment of persistent pain after LASIK. Dr. Galor has evaluated the efficacy of several therapies in treating neuropathic ocular pain and has focused on how ocular surface symptoms affect quality of life. She was also named to the 2021, 2022 and 2023 Power Lists.

Steven Gedde, M.D.

Bascom Palmer’s vice chair of education and the John G. Clarkson Chair in Ophthalmology, Dr. Gedde is an outstanding physician, researcher and educator. During his 21-year tenure as residency program director, Bascom Palmer’s training program was continually recognized as one of the best in the nation. He is a glaucoma expert whose research has focused on improving patient care through clinical trials. Dr. Gedde was also named to the 2022 Power List.

Ranya Habash, M.D.

A refractive cataract surgeon and comprehensive ophthalmologist, Dr. Habash is a voluntary assistant professor of ophthalmology. She is a digital health serial entrepreneur with a unique background in medicine’s clinical, technical and business sides. As the former medical director of technology at Bascom Palmer and part of the FDA’s Digital Health Network of Experts, Dr. Habash drives future technologies in health care. She was also named to the 2017, 2021, 2022 and 2023 Power Lists.

Carol Karp, M.D.

The Richard K. Forster Chair in Ophthalmology and Dr. Ronald and Alicia Lepke Endowed Professorship in Corneal and External Diseases, Dr. Karp is an expert in managing ocular surface oncology and anterior segment surgery. In the late 1990s, she pioneered the use of interferon to treat ocular surface squamous neoplasia. Her work has helped to change the standard of care for these lesions. Dr. Karp was also named to the 2019, 2021 and 2023 Power Lists.

Jaclyn Kovach, M.D.

A professor of clinical ophthalmology, Dr. Kovach is an internationally recognized leader in the field of retina research and care. An accomplished clinician and educator, she has presented her impactful research on the genetics of age-related macular degeneration and retinal imaging in lectures worldwide. Dr. Kovach created Luminaries: Profiles of Women in Academic Medicine, a book of autobiographical vignettes written by 24 colleagues to inspire the next generation of women physician-scientists. 

Byron Lam, M.D.

For more than a decade, Byron Lam, M.D., has been at the forefront of gene therapy, contributing to research studies and leading clinical trials to stabilize or restore vision. The Dr. Mark J. Daily Chair in Ophthalmology, Dr. Lam’s broad background in neuro-ophthalmology and hereditary retinal degenerations has enabled him to collaborate with basic and clinical scientists, resulting in many successful translational projects. He is the medical director of Bascom Palmer’s clinical research, encompassing its extensive gene therapy program, which includes ophthalmologists and research scientists studying various inherited eye diseases.

Felipe Medeiros, M.D., Ph.D.

The Rodgers Research Chair in Ophthalmology, Dr. Medeiros is a renowned glaucoma researcher with broad experience in bioinformatics, artificial intelligence and vision-enhancing technology. He was ranked among the top three glaucoma experts worldwide by Expertscape, an independent organization that evaluates publications and citations from more than 40,000 glaucoma specialists and researchers. Dr. Medeiros is at the forefront of identifying new clinical endpoints for clinical trials, a critical step in understanding the potential effectiveness of new glaucoma therapies.

Richard Parrish II, M.D.

A glaucoma specialist whose research interests have focused on improving patient care through clinical trials, Dr. Parrish is the Edward W.D. Norton Chair in Ophthalmology. He is a widely published author, editor-in-chief of the American Journal of Ophthalmology and a skilled editorialist who has contributed to the national narrative on innovative glaucoma surgical procedures and glaucoma screening. He edited the Bascom Palmer Eye Institute Atlas of Ophthalmology , the comprehensive ophthalmic text that set a standard for ophthalmic education. Dr. Parrish was also named to the 2018 Power List.

Philip Rosenfeld, M.D., Ph.D.

Dr. Rosenfeld played a pivotal role in developing anti-VEGF therapies for neovascular and exudative eye diseases and revolutionized the treatment of these diseases. By pioneering intravitreal Avastin (bevacizumab) therapy, his work has contributed to the prevention of blindness worldwide and saved billions of dollars in health care expenses. Dr. Rosenfeld was also named to the 2014, 2016, 2018, 2019, 2020, 2022 and 2023 Power Lists.

Sonia Yoo, M.D.

An expert in vision correction surgery , Dr. Yoo is recognized as one of the world’s most skilled cornea, cataract and refractive surgeons. Bascom Palmer’s medical director and the Greentree Hickman Chair in Ophthalmology, Dr. Yoo is interested in developing and evaluating new diagnostic and surgical technologies and laser applications. She was also named to the 2018, 2021 and 2023 Power Lists.

Bascom Palmer’s faculty members have been well-represented on the Power List since its inception in 2014. Other honorees have included Audina Berrocal, M.D. , in 2021) and Zelia Correa, M.D., Ph.D. , in 2022.

Tags: Bascom Palmer Eye Institute , Dr. Anat Galor , Dr. Byron Lam , Dr. Carol Karp , Dr. Eduardo Alfonso , Dr. Felipe Medeiros , Dr. Harry W. Flynn Jr. , Dr. Hilda Capo , Dr. Janet Davis , Dr. Kendall Donaldson , Dr. Philip Rosenfeld , Dr. Ranya Habash , Dr. Sonia Yoo , Dr. Steven Gedde , Jaclyn Kovach , Richard K. Parrish II , The Ophthalmologist Power List

Bascom Palmer Eye Institute’s “Moon Shot” Whole Eye Transplant Research Initiative

Bascom Palmer Eye Institute researchers are using a $1 million gift to galvanize their work on whole eye transplants.

Teen Regains Vision After Receiving First Topical Gene Therapy at Bascom Palmer Eye Institute at UHealth

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• Published: 03 January 2022

Ophthalmic trauma: the top 100 cited articles in Ophthalmology journals

• Alex T. Pham 1 ,
• Todd D. Whitescarver 2 ,
• Bradley Beatson   ORCID: orcid.org/0000-0002-9290-1062 1 ,
• Boonkit Purt 2   nAff8 ,
• Yoshihiro Yonekawa 3 ,
• Ankoor S. Shah 4 ,
• Marcus H. Colyer   ORCID: orcid.org/0000-0003-4411-3130 5 , 6 ,
• Fasika A. Woreta 7 &
• Grant A. Justin   ORCID: orcid.org/0000-0001-6084-6399 2 , 6  

Eye volume  36 ,  pages 2328–2333 ( 2022 ) Cite this article

742 Accesses

6 Citations

Metrics details

• Medical research
• Scientific community

To analyze the top 100 cited papers on ophthalmic trauma.

A literature search of Ophthalmology journals within the ISI Web of Science database for the most cited papers related to ophthalmic trauma.

The most cited articles were published between 1943 and 2013, the greatest number being published in 2000. Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15) published most of the articles. The institutions with the highest number of publications were Wilmer Eye Institute (10) and Massachusetts Eye and Ear Infirmary (7). Sixty-seven percent of the articles originated from the USA. The most common type of trauma studied was non-open-globe injuries and the most frequent topic studied were pathological conditions secondary to trauma (34), particularly endophthalmitis (8), and optic neuropathy (6). Articles presenting a standardized classification system for eye injury received the highest average of citations per publication. Types of research most frequently cited were observational clinical studies (62) and epidemiological studies (30); the least frequent were clinical trials (2).

This bibliographic study provides a historical perspective of the literature and identifies trends within the most highly influential papers on ophthalmic trauma. Many of these articles emerged within the past three decades and came from Ophthalmology journals that remain high impact to this day. Clinical trials have been difficult to conduct and are lacking, reflecting a critical need in ophthalmic trauma research, as most of our understanding of ophthalmic trauma comes from observational and epidemiological studies.

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Introduction.

The global incidence of eye injuries is estimated to be over 55 million each year with approximately 35% resulting in blindness or low vision [ 1 ]. In the USA, the rate of blindness or low vision resulting from serious eye injuries is at least 27% [ 2 ]. Interestingly, eye injuries have been shown to vary considerably across countries, demographics, socioeconomic status, gender, and age [ 3 , 4 , 5 , 6 ]. Significant social and economic burdens such as family care, lifestyle changes, lost time from school or work, workers’ compensation, and costly medical expenses from hospitalizations, clinic visits, treatment, and rehabilitation, may stem from ocular injuries [ 7 , 8 ]. Hence, ophthalmic trauma is a significant part of ophthalmological patient care, and analyzing the most impactful studies within the literature may reveal the scientific progress that has been made in the field and what remains to be improved.

Bibliometric analysis is a statistical method of reviewing the literature to identify patterns. The first bibliometric analysis, by Eugene Garfield in 1987, characterized the top 100 (T100) articles in the Journal of the American Medical Association ( JAMA ) [ 9 ]. Since then, there have been numerous bibliometric studies within ophthalmology. They have identified trends in research funding [ 10 ], contributions by specific countries [ 11 ], demographics [ 12 ], the impact of different journals [ 13 ], and various subspecialty research topics [ 14 , 15 ]. The purpose of this study is to identify the T100 cited clinical papers related to ophthalmic trauma to provide a historical perspective on ophthalmic trauma research and to identify avenues for future contributions in ophthalmic trauma research.

Materials and methods

The ISI Web of Science (WoS), maintained by Clarivate Analytics, was used to search for the T100 cited papers related to ophthalmic trauma. With coverage from the beginning of the 20th century, the WoS provides multidisciplinary content in the English language of over 21,000 peer-reviewed journals worldwide and continues to be one of the most trusted, widely-used citation indices for bibliometric analyses [ 16 , 17 , 18 ].

Our search included general search terms for eye trauma related to both open- and non-open-globe injuries, although we acknowledge that not every term is mutually exclusive. Our open-globe injury search terms were: open globe, corneal laceration, scleral laceration, intraocular foreign body, rupture, penetrating, perforating, firework, globe laceration, globe rupture, globe perforation, globe penetration, globe trauma, and globe injury. Our non-open-globe injury search terms were: burn, chemical burn, alkali burn, acid burn, thermal burn, abrasion, foreign body (peribulbar, corneal, orbital, conjunctival, lid, lacrimal), hyphema, microhyphema, iridodialysis, cyclodialysis, angle recession, laceration (eyelid, eyebrow, canalicular, nasolacrimal), orbit fracture, retrobulbar hemorrhage, retrobulbar hematoma, commotio, choroidal rupture, sclopetaria, traumatic optic neuropathy, shaken baby syndrome, abusive head trauma, traumatic cataract, and globe contusion.

Only one search was performed, and it was done within the WoS category “ophthalmology,” which contained 59 journals at the time of search in August 2020. No limitations were set for the date of publication of the manuscripts in the search. The search was performed utilizing the Boolean search operators “OR” and truncation marks (ie: “trauma*”, “injur*”), which is facilitated by the WoS search engine. The search was refined by publication type to include case series and original reports and excluding editorials, reviews, letters, meeting abstracts, and proceedings papers). The results were organized in descending order by times cited. Each paper was then reviewed by three authors (ATP, TDW, and GAJ) and excluded if it did not involve ophthalmic trauma, examples being articles about keratoconus or penetrating keratoplasty.

Our primary outcomes were to define the T100 most cited papers in ophthalmology with the corresponding variables: title, total citations, year published, citations per year, type of trauma (open-globe vs. non-open-globe injury), topic, and type of study. After examining the T100 papers, each article was grouped based on the following topics: classification system, epidemiology of mechanical eye injuries, treatment or management of mechanical injuries, traumatic sequelae (pathological conditions secondary to trauma), iatrogenic globe injury, pediatric trauma, prognostic tools/models, combat injuries, and simulation modeling. The type of study was determined by examining each paper and classifying them into the following categories: clinical experience (observational), randomized clinical trial (interventional), epidemiological, review, and other. Clinical experiences were further grouped into descriptive studies (case reports/case series) and analytic studies (retrospective cohort, prospective cohort, cross-sectional, and case–control). Case series and cohort studies were distinguished according to the definitions described by Dekkers et al. [ 19 ]. Basic science papers were excluded. Secondary outcomes were then: journal name, number of authors, first author, last author, and the institutions and countries of the first and last authors.

Statistical analysis was performed using Microsoft Excel (Redmond, WA). Pearson correlation coefficients were calculated to determine relationships between continuous variables. The correlation coefficients were then used to determine the t -statistic and p value. Alpha was set at 0.05 for all analyses.

The T100 most cited articles on ophthalmic trauma were identified (Supplementary Tables  1 and  2 ). The mean and median number of citations per article were 100 and 108, respectively, with a range of 67–322 citations. There were 11,571 cumulative citations, with a noticeable skew in article distribution due to 25% of citations coming from the top 13 of the T100 most cited articles. Figure  1 displays the yearly total citation count and the number of T100 articles that were published in that calendar year. The articles identified in this study were cited the most in 2011 and 2012, receiving 636 total citations that year. The earliest article was published in 1943, while the most recent article was published in 2013. The year containing the most articles in this study was 2000 with eight articles identified. There was no correlation between total citations and years since publication ( p  = 0.57).

Left y-axis: Line plot of total citations from T100 articles by year (orange). Right y-axis: Histogram of number of T100 articles published by year (blue).

Of the T100 articles, open-globe injury, non-open-globe injury, and both open- and non-open-globe injuries were studied in 26, 26, and 27 papers, respectively. The remaining papers did not provide the type of globe trauma. Table  1 lists the number of articles that covered specific topics, the total citations that these topics received, as well as the average citations per article on that topic. “Traumatic sequelae” was the most common topic that was investigated in the articles (34). Of these conditions, the most frequently studied were endophthalmitis and optic neuropathy. Articles on traumatic sequelae received the highest number of total citations (4210). However, “Classification System/Terminology” had the highest average number of citations per article, with an average of 233 citations per article despite only having three papers on this topic. Figure  2 displays the percentage of articles that fall into different research types. The majority (62%) of articles were observational clinical experiences; 25 papers were descriptive case reports/case series and 37 papers being mainly analytical cohort studies. The least frequent type of study were interventional randomized clinical trials (2%).

Distribution of T100 publications by article type: clinical experience (blue), epidemiology (yellow), clinical trial (orange), other (green).

The articles were published in 14 journals (Table  2 ). Table  2 lists the number of articles and the total citations for each journal. The American Journal of Ophthalmology published the most cited article [ 20 ], Cornea published the third most cited article [ 21 ], while Ophthalmology published the remainder of the top five most cited articles [ 22 , 23 , 24 ]. The impact factor of journals from the most recent WoS journal citation report (2019) had a strong positive correlation with the number of T100 articles ( r  = 0.856, p  < 0.01) and their combined number of citations ( r  = 0.831, p  < 0.001). The majority (77) of the T100 papers were published in Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15).

Among research institutions that have published multiple T100 papers, Wilmer Eye Institute, Johns Hopkins University, had the most articles (10) followed by Massachusetts Eye and Ear Infirmary, Harvard University (7). The first author and last author’s affiliated institution was used to determine the institutions credited with the article. Moreover, among countries with multiple T100 papers, most of the articles originated from the USA (67).

Authors who have published the most T100 papers are Ferenc Kuhn (3), Peter E. Liggett (3), Stephen J. Ryan (3), and James M. Tielsch (3). The range of authors listed in a single article was 1 to 13 authors. The median number of authors was four, and there were four articles with a single author. In total, there were 93 papers with unique first authors and 94 unique last authors.

Ophthalmic trauma is a preventable cause of vision loss that can drastically affect one’s quality of life [ 25 ]. There have been numerous publications, especially within the last three decades, dedicated to studying ophthalmic trauma to better understand its risks, outcomes, and management. There were noticeable trends observed between the T100 articles and the journals in which they were published. A significant positive correlation was found between the journal impact factor and the number of T100 articles it published and their total citations. The majority (77) of T100 articles were published in high-ranking journals (impact factor >4.00), specifically, Ophthalmology , Archives of Ophthalmology (now JAMA Ophthalmology ), and the American Journal of Ophthalmology . This is similar to a bibliometric analysis of intravitreal injection papers [ 26 ]. These findings speak to the clinical utility of not only ophthalmic trauma papers but highly cited papers in general, as these journals also may prefer to select studies that are deemed important for all practicing ophthalmologists regardless of subspecialty [ 16 ].

The majority (67) of the most cited ophthalmic trauma articles originated from the USA, which is similar to previous bibliometric studies within ophthalmology [ 26 , 27 , 28 ]. This trend has been attributed to a combination of the size of the US ophthalmology community, its resources, research output, and that many journals are US-based [ 27 ]. Bias from US authors and reviewers may also play a role [ 29 , 30 ]. This trend may be changing, however, where many recent bibliographic papers show tremendous growth in the number of papers published by institutions outside of the USA [ 6 , 14 ]. There may be a publication time bias, however, where the relatively new papers may not have been in existence long enough to garner citations, and newer journals may not be indexed yet.

Of the T100 papers on ophthalmic trauma, 26, 26, and 27 papers studied open-, closed-, and both open/non-open-globe injuries, respectively. Among these papers, a variety of traumatic sequelae were studied (32 articles published articles; 4334 total citations), but the most common was endophthalmitis (eight articles; 859 total citations) [ 22 , 23 , 31 , 32 , 33 , 34 , 35 ]. This is not surprising as endophthalmitis is a major concern in any traumatized eye and its development has significant effects on clinical course [ 36 ].

The second most studied sequelae were traumatic optic neuropathy, and these investigations were driven by the motivation to establish a consensus on the proper method of clinical management [ 31 , 32 , 34 , 35 ]. An important study of note is the International Optic Nerve Trauma study, which was the first organized study to investigate the treatment of indirect traumatic optic neuropathy [ 22 ]. This investigation was initially intended to be a randomized, controlled, pilot study but due to the rarity of the condition, recruiting eligible patients proved to be a significant challenge. Consequently, it was transformed into a comparative, nonrandomized, noncontrolled interventional study that concluded there was no clear benefit for either corticosteroid therapy or optic canal decompression. This study exemplified a major hallmark, but also a challenge, in ophthalmic trauma literature: the paucity of clinical trials and the obstacles associated with conducting one. The least frequent type of research study in this bibliometric analysis was interventional, randomized clinical trials (2). Eye injuries have a heterogeneous presentation with many confounding variables that make it difficult to control for significant individual variability [ 37 ]. This consequently makes it challenging to independently evaluate various risk factors and treatment modalities [ 22 ]. In addition, up to a quarter of patients with ophthalmic emergencies can be lost to follow-up from the emergency department [ 38 ]. Hence, the majority of ophthalmic trauma literature has been limited to observational clinical experiences (60) consisting mostly of descriptive case studies or reports (25) and analytical cohort studies (34). This highlights the need for the future of research in these topics through clinical trials.

The second most common type of research study was epidemiological studies. While there were 30 epidemiological research articles related to ophthalmic trauma, only a portion of the studies were focused primarily on mechanical eye injuries (16 articles; 1487 total citations) [ 2 , 4 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Since ophthalmic trauma is considered to be an avoidable cause of vision loss with significant medical, social, and economic consequences, it is expected that many studies seek to understand the incidence and risk factors of ophthalmic trauma to create preventative interventions and reduce its national burden. The remaining 14 epidemiology articles related to other topics: keratitis (4), endophthalmitis (4), corneal ulcerations (2), pediatric eye injuries (2), proliferative vitreoretinopathy (1), and war injuries (1).

A major milestone in ophthalmic trauma literature was the creation of a standardized system for classifying mechanical globe trauma [ 20 , 24 ]. Previously, the terminology used by ophthalmologists varied considerably, and this impinged proper discussions of ophthalmic trauma. Thus, landmark classification articles receive a high number of citations because any scientific investigation on ophthalmic trauma needs to describe the mechanism of injury or type of trauma involved in the study to effectively communicate eye injury information. Classification articles are less common in comparison to other topics within the T100 articles. Yet, despite having fewer articles, the average citation per article is higher (233 citations per article) than any other topic, which suggests that individual articles on this topic have had the greatest impact within the field.

This study has several limitations. The list of the T100 most cited articles generated differs depending on the database used, the search parameters, and the search terms used. First, we used the WoS due to its extensive database and widespread use in bibliometric analysis, but literature predating 1980 is scarce and cataloging is less reliable. There is variation between the WoS and other databases like Google Scholar or Scopus. Hence, using multiple databases would provide a more comprehensive picture of the literature [ 50 , 51 ]. Second, our search only included journals within the field of ophthalmology, which could exclude trauma papers published in high-impact basic science journals and other general medical journals, that may have potentially been within the T100 most cited articles. Third, a broad list of search terms was used that led to over 15,000 results, which were manually searched to the T100. This presents a greater possibility of human error or bias in selecting relevant ophthalmic trauma articles. Finally, our study determines the impact of an article through the number of citations it has received since publication. It is important to note, however, that potentially more impactful articles simply may not have had the time to generate the citation counts as older articles. Older, yet highly impactful articles may also have been missed in our search because their contents have become common knowledge; hence, they are cited less frequently [ 27 ].

Overall, this study is a bibliometric analysis of the 100 most cited articles in ophthalmic trauma. We found many studies originated from the U.S. and were published in leading Ophthalmology journals. The most common topics studied were pathological conditions secondary to ophthalmic trauma, specifically endophthalmitis, and traumatic optic neuropathy. Many studies have been limited to clinical experiences due to the challenges of conducting a proper clinical trial with traumatic eye injuries. Most of the literature is comprised of observational clinical and epidemiological studies. Lastly, despite having a fewer number of publications, a standardized system of classification for mechanical eye injuries was a major development in the field of ophthalmic trauma with a significant impact on citations.

What was known before

Ophthalmic trauma has a significant impact on quality of life and is associated with poor vision outcomes.

There are numerous bibliometric studies within ophthalmology that have identified several publication trends in various subspecialty research topics, but none on ocular trauma.

What this study adds

A historical perspective of ophthalmic trauma literature that identifies trends in the most highly cited papers.

Demonstrates a paucity in clinical trial research in ophthalmic trauma.

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of the San Antonio Military Medical Center, the Walter Reed National Military Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Air Force, the Department of the Army, Department of Defense, the Defense Health Agency, or any other agency of the U.S. Government.

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Alex T. Pham & Bradley Beatson

Department of Ophthalmology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, USA

Todd D. Whitescarver, Boonkit Purt & Grant A. Justin

Wills Eye Hospital Retina Service, Mid Atlantic Retina, Thomas Jefferson University, 840 Walnut St, Philadelphia, PA, 19107, USA

Yoshihiro Yonekawa

Departments of Ophthalmology, Boston Children’s Hospital, Massachusetts Eye & Ear and Harvard Medical School, 300 Longwood Ave, Fegan 4, Boston, MA, 02115, USA

Ankoor S. Shah

Department of Ophthalmology, Madigan Army Medical Center, Tacoma, WA, 98431, USA

Marcus H. Colyer

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Pham, A.T., Whitescarver, T.D., Beatson, B. et al. Ophthalmic trauma: the top 100 cited articles in Ophthalmology journals. Eye 36 , 2328–2333 (2022). https://doi.org/10.1038/s41433-021-01871-w

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Consumer Reviews for OTC Eye Care Products May Be Misleading

Also, safety profile doesn’t necessarily correlate with popularity, arvo study shows. regulatory oversight could improve public safety, researchers suggest..

In light of recent safety recalls for retail eye drops, it’s “buyer beware” for many over-the-counter ocular products. Research presented last week at ARVO looked at top-selling eyecare products on Amazon and their descriptive data and found that there are major discrepancies between Amazon consumer reviews and ratings and a product’s safety.

The cross-sectional study examined the 100 top-selling OTC eyecare products on Amazon and the product information, including cost, ratings, ingredients, manufacturer, country of origin, marketing claims and more. Researchers gathered allergen information and cross-referenced it with the American Contact Dermatitis Society and North American Contact Dermatitis Group allergen databases. They obtained recall information and adverse event data from the FDA and adjusted consumer ratings for false reviews using Fakespot.

The group’s findings showed that 52% of products contained allergens, such as benzalkonium chloride (23%), propylene glycol (15%) and polysorbate 80 (11%). One product was recalled. They noted that price-per-ounce wasn’t associated with allergens, more reviews or unadjusted ratings, but they did notice that after removing the fake reviews, the price-per-ounce was associated with higher adjusted ratings. Adverse events and allergens weren’t associated with product ratings.

Based on these results, the researchers concluded in their ARVO abstract that “despite widespread reliance on consumer metrics such as pricing, reviews, ratings and marketing claims, these factors do not consistently align with the safety metrics of OTC eyecare products. Furthermore, the discrepancies between Amazon-provided and fake-adjusted ratings underscore the need for more robust and transparent review systems. As the OTC eyecare product industry continues to grow, a combined effort from regulatory bodies, manufacturers and healthcare professionals is imperative to ensure product safety and maintain consumer trust.”

Original abstract content @2024 Association for Research in Vision and Ophthalmology.

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• Potential Complications from Contact Lens Use
• Preventing Eye Infections When Wearing Contacts

At a glance

• When cared for properly, contact lenses can provide a safe and effective way to correct your vision.
• Taking proper care of your contact lenses can help you see better and keep your eyes healthy.

Contact lenses are an effective way to correct vision, but they must be worn and cared for properly to avoid eye infections. Your habits, supplies, and eye care provider are all essential for maintaining healthy eyes.

By following your eye care provider's instructions on how to properly wear, clean, and store your lenses, you can enjoy the comfort and benefits of contact lenses while lowering your chances of eye complications.

Prevention steps and strategies

Contact lenses are medical devices and are not risk-free. Follow these healthy habits to safely wear contact lenses and help protect your eyes:

Practice eye care hygiene

• Avoid sleeping in lenses unless directed by your eye care provider.
• Wash hands thoroughly with soap and water before handling lenses.
• Dry hands completely with a clean cloth before touching lenses.

Keep contact lenses away from all water

• Remove before swimming or showering to prevent germ exposure.

Properly clean your lenses

• Use recommended contact lens solution.
• Rub and rinse lenses with disinfecting solution.
• Avoid mixing fresh and old solution in the case.

Take care of your contact lens case

• Clean case with solution by rubbing and rinsing.
• Store case upside down with caps off after each use.
• Replace case at least once every three months.

Consult your eye care provider

• Discuss contact lens wear and care habits and potential concerns.
• Visit your eye care provider yearly or as recommended.
• Remove lenses and contact eye care provider if experiencing discomfort.

Be Prepared

• Carry backup glasses with current prescription in case you have to take out your contact lenses.

Why prevention is important

Wearing contact lenses brings benefits like better vision and convenience, but taking good care of them is essential. Proper care prevents infections and maintains eye health.

To get the most out of your contact lens-wearing experience, be sure to always practice healthy eye care habits. Following care instructions and replacing lenses when advised ensures optimal eye health and clear vision.

Travel tips for people who wear contact lenses

Don't let an eye infection ruin your travels. Take care of your contact lenses to fully enjoy your destination. Follow these tips to prevent contact lens-related eye infections while preparing for your trip.

Before you go

• Ensure your prescription is current by visiting your eye care provider annually.
• Replace your contact lens case every three months.
• Pack backup supplies: lens case, contacts, glasses, and solution.

During your trip

• Remove lenses before sleeping, showering, or swimming to prevent infections.
• Follow replacement schedule recommended by your eye care provider.
• Use fresh contact lens solution for storage, never water.
• Avoid mixing old and new solution.
• Only use prescribed lenses to avoid risks to eye health and sight.

Healthy Contact Lens Wear and Care

Contact lenses are medical devices, and failure to wear, clean, and store them as directed can increase the risk of eye infections, such as microbial keratitis.

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The doctor is in.... but what's behind them?

Americans have gotten used to seeing their doctors and other health care providers using telehealth video visits in the past four years. But a new study reveals that what a doctor has behind them during a telehealth visit can make a difference in how the patient feels about them and their care.

Even if the doctor is miles away from their usual in-person clinic or exam room, they should make it look like they're there, the study suggests.

Even better: sitting in an office with their diplomas hanging behind them -- or perhaps having a virtual background that's a photo of such an office. This is especially true if they haven't seen the patient before, the study shows.

A home office with a bookshelf or a plain solid-color background are both acceptable to patients, too.

But providers should use blurred or virtual backgrounds if they carry out the visit in a home environment with a kitchen or a bed in the background, the study shows.

The findings come from a survey that asked patients to react to seven different backgrounds behind a model physician, and to rate how knowledgeable, trustworthy, caring, approachable and professional the physician appeared in each, and how comfortable the patient would feel with that provider. It also asked them to consider each background for a first or returning appointment with a primary care or specialty provider.

The study is published in JAMA Network Open by a team from the University of Michigan's academic medical center, Michigan Medicine, and the VA Ann Arbor Healthcare System. More than 1,200 patients who had seen providers at one of the two health systems completed the study surveys, and the researchers compiled their responses.

Lead researcher Nathan Houchens, M.D., is an associate professor of internal medicine at U-M and associate chief of medicine at VAAAHS. His past work on how interpersonal communications affects the patient-provider relationship -- including non-verbal factors like attire and posture -- led to the new telehealth study.

"The transition to virtual care was rapid and came without specific guidance during the start of the COVID-19 pandemic, but telehealth appears to be here to stay so it's important to understand what patients prefer when it comes to the setting their provider is in," says Houchens, a hospitalist who worked with U-M and VA general internist Jennifer Meddings, M.D., M.Sc. and others on the study.

He notes that during the first year of the pandemic, providers were urged to conduct telehealth visits outside of clinics if they didn't need to go in, to reduce the chance of COVID-19 transmission.

But now, some clinics have created dedicated spaces for providers to sit in if they have telehealth appointments on days when they're also seeing patients in person. Some of those might be spaces shared with other clinicians, so a virtual background would also serve to reduce visual distractions.

Houchens notes that as telehealth increased in use and became a standard way to receive care, some guidance on "webside manner" has been suggested to guide providers in the ways in which they interact verbally over a virtual connection. But very little guidance is available about the background for their video visits.

He and his colleagues were surprised at the level of dislike that patients had for kitchen and bedroom settings, with only 2% and 3.5% saying they preferred these backgrounds respectively, compared with 35% for an office with displayed diplomas, 18% for a physician office, 14% for a plain color background, and around the same for a home office with bookshelf or an exam room.

There were also significant differences in the composite scores for how patients rated the way each background would make them feel about receiving care from the provider. The bedroom and kitchen backgrounds received far lower composite scores than any of the other five backgrounds.

Houchens and colleagues including co-author Sanjay Saint, M.D., M.P.H., have previously published work on patients' preferences for what physicians wear during clinical encounters. Just like with video visit background, these seemingly superficial factors can actually make a difference in the patient experience, he says.

"Patients have expectations of what physicians' attire and workspaces should look like. This study showed that patients prefer what have been previously termed traditional or professional attire and settings," he said. "Diplomas and credentials remind patients of the expertise they expect a physician to have, and conversely, something is lost when the background conveys a relaxed, informal home environment."

The team is currently analyzing more data from the same study, to assess other factors that affect patients' telehealth experiences -- including their access to high-speed internet and their ability to use necessary technologies.

But for now, they suggest that providers can take immediate steps to conduct virtual visits from an office or exam room. Clinics may want to make unused clinical rooms available for use by providers conducting virtual visits during in-person clinic days.

Another option is to create virtual backgrounds that will evoke these types of professional settings.

Houchens also notes that while they haven't yet studied what physicians think of the backgrounds behind patients during video visits, these may provide helpful information.

The rise of "Hospital at Home" and home-based primary care means that patients with more acute conditions may be able to see their providers virtually, and that their setting can give clues to the way physical and social factors play a role in their health. Discussing visible elements from both a provider's and a patient's virtual background -- art and other hobby-related items, for example -- can also help build rapport, Houchens notes.

"This is a reminder that patients often do care about some of the details that providers and health systems may not have emphasized," he said. "It's important to remember that our words and our nonverbal behaviors are taken to heart by those we care for, and it behooves us to care about them as well."

Meddings and Saint are members of the VA Center for Clinical Management Research and the U-M Institute for Healthcare Policy and Innovation.

In addition to Houchens, Meddings and Saint, the study's authors are Latoya Kuhn MPH, David Ratz MS, Jason M. Engle MPH of VA CCMR.

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Materials provided by Michigan Medicine - University of Michigan . Original written by Kara Gavin. Note: Content may be edited for style and length.

Journal Reference :

• Nathan Houchens, Sanjay Saint, Latoya Kuhn, David Ratz, Jason M. Engle, Jennifer Meddings. Patient Preferences for Telemedicine Video Backgrounds . JAMA Network Open , 2024; 7 (5): e2411512 DOI: 10.1001/jamanetworkopen.2024.11512

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