Seven-year experience in a low vision rehabilitation clinic at a tertiary referral center

Abbas Riazi, Reza Gharebaghi, Fatemeh Heidary

Medical hypothesis, discovery & innovation in optometry, Vol. 3 No. 4 (2022), 14 January 2023 , Page 128-135

Background: Low vision is a major public health concern worldwide. This study was aimed at describing the characteristics of patients who had visited a low-vision rehabilitation clinic.
Methods: In this retrospective study, we reviewed the medical records of patients with low vision attending a low-vision rehabilitation clinic at a tertiary referral center over 7 years. Inclusion criteria were a diagnosis of vision impairment and availability of complete records. We extracted the following data from each record: age, sex, education level, employment status, chief complaints concerning vision, associated ocular diseases, uncorrected distance and near visual acuities, best-corrected distance and near visual acuities, statuses of previous and current prescribed optical devices, and cooperation status of patients during the optometric examination.
Results: We enrolled a total of 567 patients, including 338 (59.6%) men and 229 (40.4%) women, with a mean (standard deviation) age of 40.46 (28.34) years. Most (98.4%) participants were cooperative, with a high rate of unemployment (90.5%) and low education level. Half (49.2%) of the patients had moderate visual impairment. Retinal pathologies, mainly congenital (28.4%), and age-related macular degeneration (ARMD; 26.5%) were common causes of low vision. Difficulty in reading was the most frequent complaint (22.9%), and a combination of difficulties in reading, writing, and facial recognition was recorded in 54.7% of the patients. Other functional complaints were reported by at least 5% of the patients. Our multivariate logistic regression analysis revealed that the likelihood of difficulties in performing in-house activities, reading, facial recognition and social interaction, and driving increased per 10-year increment in age, with odds ratios of 1.39, 1.31, 1.24, and 1.22, respectively (all P < 0.05). The likelihood of reporting three complaints (reading, writing, and facial recognition together) increased per 0.1-logarithm of the minimum angle of resolution increment in the best-corrected distance visual acuity of the better eye, with an odds ratio of 2.05 (P < 0.05). In addition, men were more likely to experience difficulties in driving and reading, while women were more likely to experience difficulties in facial recognition and social interaction or in-house activities (all P < 0.05). Optical devices for distance or near vision were prescribed to most patients.
Conclusions: Most patients were men and unemployed. The most common category of low vision was moderate impairment. Retinal conditions, mainly congenital ones and ARMD, were the most frequent causes. A combination of difficulties in reading, writing, and facial recognition was the most common complaint. Optometrists should address these findings during rehabilitation therapy to treat patients with low vision.

Myopia progression in children before and after the coronavirus disease lockdown

Prema K Chande, Neepa Thacker Dave, Mumtaz Qazi, Priyanka Bapat Vora

Medical hypothesis, discovery & innovation in optometry, Vol. 3 No. 4 (2022), 14 January 2023 , Page 136-141

Background: The worldwide spread of the coronavirus disease (COVID-19) pandemic in 2020, followed by lockdowns, forced children to be in home confinement with increased screen time, leading to rapid progression of myopia and an increase in the prevalence of myopia. This study was aimed at determining if myopia progression seen in evidence-based practice resulted from the COVID-19 lockdown or delayed follow-ups.
Methods: A retrospective review of case sheets of patients visiting the pediatric department of a tertiary care eye hospital in Mumbai, India, was conducted from 2017 onwards. We enrolled all children with myopia who had attended at least one follow-up visit before the COVID-19 lockdown and at least one follow-up visit post-lockdown. The spherical equivalent (SEQ) of refractive error values at baseline and pre- and post-COVID-19 lockdown follow-ups (hereinafter referred to as the “first” and “second” follow-ups, respectively) were recorded. The duration between baseline and the first follow-up visit and between the first and second follow-up visits were noted.
Results: We enrolled 112 eyes of 56 children, including 35 (62.5%) boys and 21 (37.5%) girls, with a mean (standard deviation [SD]) age of 9.54 (2.82) years. The mean (SD) SEQ values at baseline and first and second follow-ups were - 4.74 (3.83), - 5.46 (3.81), and - 6.42 (3.66) D, respectively. The mean change in SEQ, mean SEQ myopia progression, and rate of myopia progression per month differed significantly between the baseline and the first follow-up visit versus between the first and second follow-ups (all P < 0.05). However, the change in myopia degree did not differ significantly between these two periods in eyes with low, moderate, or high myopia (all P > 0.05). The mean (SD) duration between the baseline and the first follow-up visit was 14.57 (5.68) months, while that between the first and second follow-ups was 27.96 (9.18) months, showing a significant difference (P < 0.05).
Conclusions: Our findings suggest that a longer gap between follow-up visits and myopia progression per month should be factored into the management of myopia. Considering that young children are more vulnerable, preventive measures and school reforms should be urgently implemented in India. Further retrospective multicenter studies with a larger sample size of eyes, including various refractive errors over a longer period, are required to verify these findings.

Impact of vision correction on the visual impairment status and quality of life score in patients with type II diabetes mellitus

Noor Suriani Mohamad, Chiranjib Majumder, Rokiah Omar

Medical hypothesis, discovery & innovation in optometry, Vol. 3 No. 4 (2022), 14 January 2023 , Page 142-151

Background: Visual impairment (VI) in patients with diabetes mellitus (DM) worsens as the disease progresses. Therefore, quality of life (QOL) may also be affected. Furthermore, in the absence of macular involvement, some patients may benefit from visual intervention. However, not many Malaysians with known DM had their eyes screened or used correctable spectacles. Consequently, the QOL and VI status of patients with DM in Malaysia remain unclear. This study was aimed at determining the impact of optometric intervention on the QOL and VI status of adults with type II DM.
Methods: This was a quasi-self-controlled, experimental study involving adults with known type II DM. We conducted face-to-face interviews using the low vision quality-of-life questionnaire (LVQOL). The habitual visual acuity (VA) of all participants was recorded. All participants underwent fundus photography to grade diabetic retinopathy (DR) in both eyes. Correctable VA was determined following subjective refraction when the best-corrected distance visual acuity (BCDVA) was 6 /9 and better. After a 3-week adaptation to the prescribed refractive error correction, LVQOL was repeated via a phone interview.
Results: A total of 47 participants with type II DM, including 16 (34%) men and 31 (66%) women, with a mean (standard deviation [SD]) age of 49.0 (7.9) years were recruited. The age range was 32 – 59 years, and the baseline mean (SD) habitual binocular VA was 0.52 (0.31) decimal. Only 15% (n = 7 patients) of the participants had their vision tested and wore glasses; however, some were uncomfortable with the current corrections. All patients had undercorrected or uncorrected refractive errors, namely, hyperopic astigmatism (47%), myopic astigmatism (38%), hyperopia (6%), myopia (4%), and antimetropia (4%). Among the 47 participants, 89% (n = 42) had uncorrected presbyopia. The mean (SD) LVQOL score at baseline was 91.9 (17.3), which improved significantly with visual intervention to 122.8 (3.2) (P < 0.05). Refractive error corrections significantly improved the VI status (P < 0.05), as all participants achieved a BCDVA of 6 / 9 and better.
Conclusions: Our findings indicate that optometric intervention is effective in improving the LVQOL and VI status of adults with type II DM. Further clinical optometric studies on type II DM with DR with a longer follow-up should be carried out to understand the clinical characteristics of this cohort and the impact of meticulous refractions on QOL in providing better services in the future.

Anterior-segment optical coherence tomography for tacrolimus therapy response monitoring of vernal keratoconjunctivitis

Mahmoud Eltagoury, Waleed Abou Samra, Ehab Ghoneim

Medical hypothesis, discovery & innovation in optometry, Vol. 3 No. 4 (2022), 14 January 2023 , Page 152-159

Background: Vernal keratoconjunctivitis (VKC), a chronic bilateral eye disease, is a severe form of allergic conjunctivitis. Anterior-segment optical coherence tomography (AS-OCT) is a rapid, noninvasive, in vivo visualization modality for the anterior segment structures that has been used in diagnosing and staging diseases and assessing the treatment efficacy. We used anterior-segment optical coherence tomography (AS-OCT) to monitor the efficacy of the tacrolimus eye ointment in managing VKC.
Methods: In this prospective follow-up study, we included patients with active symptomatic VKC. All patients were treated with the 0.03% tacrolimus ophthalmic ointment twice daily for 2 months and then once daily for 1 month. All patients underwent AS-OCT before and 3 months after treatment as an objective method to assess the treatment efficacy.
Results: We included 20 eyes of ten patients (nine men and one woman) with active symptomatic VKC. The mean age was 17.3 (range: 11 – 36) years, with nine patients having a palpebral type and one patient having a mixed type of VKC. Substantial flattening and reduction in the papilla size were observed in all patients at the post-treatment follow-up. AS-OCT measurements revealed significant reductions in the vertical, horizontal, and total diameters of the palpebral papillae and limbal conjunctival thickness after 3 months of treatment compared to baseline measurements (all P < 0.001). No serious adverse effects attributable to tacrolimus administration were observed in the study period.
Conclusions: AS-OCT is a suitable objective method for evaluating the treatment efficacy of the 0.03% tacrolimus eye ointment in patients with VKC. Future large-scale studies including a wide range of age groups with longer follow-up periods and AS-OCT monitoring at multiple post-treatment visits are required to confirm our preliminary results. Moreover, the diagnostic accuracy of AS-OCT in monitoring patients with active VKC should be tested in comparison with objective scoring by an experienced corneal fellowship.

Vortex keratopathy after photorefractive keratectomy in a patient on long-term clozapine treatment

Samir Shoughy, Hosam Elgemie, Waleed Nasif

Medical hypothesis, discovery & innovation in optometry, Vol. 3 No. 4 (2022), 14 January 2023 , Page 160-164

Background: Vortex keratopathy is a corneal entity characterized by corneal deposits at the level of the basal epithelium in the form of a whorl-like pattern in the interpalpebral portions of the cornea. Medications such as amiodarone, chloroquine, hydroxychloroquine, indomethacin, phenothiazines, ibuprofen, and naproxen bind to the cellular lipids of the basal epithelial layer of the cornea, producing a characteristic whorl pattern. Here, we report a case of bilateral central vortex keratopathy with slight vision impairment 3 weeks after uneventful photorefractive keratectomy (PRK) in a woman on long-term clozapine treatment.
Case Presentation: A 42-year-old woman presented to the outpatient clinic for refractive surgery for the correction of bilateral moderate myopia. Her best-corrected distance visual acuity was 20 / 20 in both eyes. She had been on antipsychotic clozapine tablets 400 mg / day for the past 6 years to manage a psychiatric disorder. On detailed preoperative slit-lamp examination, her corneas were clear, with perilimbal conjunctival pigmentations. Other ocular examination results were unremarkable. At the 3-week follow-up after an uneventful PRK, her uncorrected distance visual acuity was 20 / 25 in the right eye and 20 / 20 in the left eye, with complaints of slightly unclear vision in both eyes. Slit-lamp examination revealed bilateral corneal subepithelial deposits in a whorl-like pattern reminiscent of vortex keratopathy. The deposits were restricted to the epithelial and subepithelial regions and did not extend to the stroma without evident stromal haze. Dilated fundus examination results were normal bilaterally. Despite excellent refractive outcomes and visual acuity in both eyes, she was dissatisfied and complained of unclear vision. She was administered with lubricating eye drops and placed on regular follow-ups. At the 4-month follow-up, the vortex lines were cleared centrally, and she reported improvement in vision. Anterior-segment optical coherence tomography of the cornea revealed no epithelial deposits in the central part of the cornea and residual deposits in the temporal peripheral cornea, indicating clearing of the deposits from the central cornea and explaining the subjective improvement in vision. Her final best-corrected distance visual acuity was 20/20 in both eyes with an unremarkable ocular examination.
Conclusions: Our case indicates a potential causal relationship between long-term clozapine treatment and development of temporary, visually significant vortex keratopathy after uneventful PRK. Further large-scale studies are required to verify the causal relationship between the long-term clozapine administration and the development of vortex keratopathy following surface ablation photorefractive procedures.