Topical glaucoma medications:Clinical implications for the ocular surface

Glaucoma is a leading cause of irreversible blindness. The use of topical eye drops to reduce intraocular pressure remains the mainstay treatment. These eye drops frequently contain preservatives designed to ensure sterility of the compound. A growing number of clinical and experimental studies report the detrimental effects of not only these preservatives but also the active pharmaceutical compounds on the ocular surface, with resultant tear film instability and dry eye disease. Herein, we critically appraise the published literature exploring the effects of preservatives and pharmaceutical compounds on the ocular surface

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

HINTS på legevakt - for å skille mellom perifer og sentral årsak til akutt vertigo. Et kvalitetsforbedringsprosjekt

Tema/problemstilling: Vertigo er en potensielt alvorlig problemstilling på legevakt, og kan skyldes patologi i CNS eller perifere nerver og organer. Det kan være vanskelig å skille mellom sentral og perifer årsak. Resultatet er ofte unødvendige innleggelser med mistanke om slag. HINTS er et testbatteri bestående av tre øyemotilitetsundersøkelser som kan bidra til å skille mellom perifer og sentral årsak til vertigo. Vi har beskrevet et kvalitetsforbedringsprosjekt med implementering av HINTS ved Nedre Romerike Legevakt. Kunnskapsgrunnlaget: Kvalitetsforbedringsprosjektet baserer seg på anbefalinger og retningslinjer fra NevroNEL og UpToDate. Studiene i kunnskapsgrunnlaget viser til gode testegenskaper for HINTS, spesielt kort tid etter symptomdebut. Selv om studiene er små av størrelse, GRADE-vurderes graden av evidens til 1B (sterk anbefaling, moderat kunnskapsgrunnlag). Tiltak/kvalitetsindikatorer: Hovedtiltak for implementering av HINTS er innføring av en intern prosedyre. For å evaluere effekt av implementering, har vi utarbeidet to prosessindikatorer; andel med vertigo hvor HINTS ble benyttet, og andel vertigopasienter som henvises til Akershus Universitetssykehus med spørsmål om slag. Målet i den første perioden av prosjektet er at 50% av vertigopasientene skal evalueres med HINTS, og det absolutte antallet henvisninger til Akershus Universitetssykehus skal falle fra baselinemålingen. Ledelse/organisering: Prosjektet ledes av en prosjektledergruppe, i tillegg er alle leger ved legevakten er prosjektdeltagere. Prosjektledergruppen er ansvarlig for å følge den gjennomføringsplanen som er skissert, samt evaluere effektmålingene underveis. Gjennomføringsplanen viser hvordan man skal innføre prosedyren, drive undervisning, opplæring og registrere effektmålinger. Den tar også for seg hvordan man kan møte utfordringer i implementeringsprosessen, og hvordan man skal kunne håndtere motstand knyttet til endringen. Konklusjon: Med en GRADE 1B anbefaling fra kunnskapsgrunnlaget, et ønske om implementering fra legene ved legevakten, og få forutsigbare utfordringer ved implementeringsprosessen, konkluderes det med at kvalitetsforbedringsprosjektet med implementering av HINTS ved Nedre Romerike Legevakt, bør gjennomføres

Topical glaucoma medications – Clinical implications for the ocular surface

Glaucoma is a leading cause of irreversible blindness. The use of topical eye drops to reduce intraocular pressure remains the mainstay treatment. These eye drops frequently contain preservatives designed to ensure sterility of the compound. A growing number of clinical and experimental studies report the detrimental effects of not only these preservatives but also the active pharmaceutical compounds on the ocular surface, with resultant tear film instability and dry eye disease. Herein, we critically appraise the published literature exploring the effects of preservatives and pharmaceutical compounds on the ocular surface

Topical glaucoma medications – Clinical implications for the ocular surface

Glaucoma is a leading cause of irreversible blindness. The use of topical eye drops to reduce intraocular pressure remains the mainstay treatment. These eye drops frequently contain preservatives designed to ensure sterility of the compound. A growing number of clinical and experimental studies report the detrimental effects of not only these preservatives but also the active pharmaceutical compounds on the ocular surface, with resultant tear film instability and dry eye disease. Herein, we critically appraise the published literature exploring the effects of preservatives and pharmaceutical compounds on the ocular surface

Visual Contrast Sensitivity Correlates to the Retinal Degeneration in Rhodopsin Knockout Mice

Purpose: Clinical manifestations of photoreceptor degeneration include gradual thinning of the outer nuclear layer (ONL) and progressive reduction of electroretinogram (ERG) amplitudes and vision loss. Although preclinical evaluations of treatment strategies greatly depend on rodent models, the courses of these changes in mice remain unclear. We thus sought to investigate the temporal correlations in changes of spatial vision, ERG response, and ONL thickness in mice with progressive photoreceptor degeneration. Methods: Adult wild-type (WT) mice and mice carrying rhodopsin deficiency (Rho−/−), a frequently used mouse model of human retinitis pigmentosa, were selected for investigation. Mouse spatial vision, including visual acuity (VA) and contrast sensitivity (CS), was determined using optomotor response (OMR) assays; ONL thickness was quantified by spectral-domain optical coherence tomography (SD-OCT), and ERG was performed to evaluate retinal functions. The mice were killed when they were 14 weeks old, and the cone photoreceptors in retinal sections were counted. Results: Spatial vision, ONL thickness, and ERG amplitudes remained stable in WT mice at all examined time points. While 6-week-old Rho−/− mice had VA, CS, as well as ERG responses similar to those of WT mice, progressive reductions in the spatial vision and retinal functions were recorded thereafter. Most tested 12-week-old Rho−/− mice had no visual-evoked OMR and ERG responses. Moreover, CS, but not VA, displayed a linear decline that was closely associated with ONL thinning, reduction of ERG amplitudes, and loss of cones. Conclusions: We presented a comprehensive study of the relation between the changes of spatial vision, retinal function, and ONL thickness in postnatal week (PW)6 to PW12 Rho−/− mice. CS is a more sensitive indicator of spatial vision compared to VA, although both are required as separate parameters for monitoring the visual changes in retina undergoing photoreceptor degeneration

Meibomian gland features in a Norwegian cohort of patients with primary Sjögren´s syndrome.

Purpose To assess the tear film and meibomian gland (MG) features in a Norwegian cohort of patients with primary Sjögren´s syndrome (pSS) and in age- and gender-matched control subjects. Methods Thirty-four female patients with pSS (age 52.9±11.9 years) and 32 female control subjects (age 49.0±11.5 years) were recruited. After completion of Ocular Surface Disease Index (OSDI) questionnaire and McMonnies Dry Eye Questionaire, participants underwent measurements of tear osmolarity, tear break-up time (TBUT), ocular surface and corneal staining, Schirmer I test, corneal sensitivity, MG expressibility evaluations, and lid margin morphology examination using slitlamp microscopy. Non-contact infrared meibography images were assessed by computer-assisted analysis. The MG loss, calculated as (tarsal area-MG area)/tarsal area, was evaluated in both upper (UL) and lower lids (LL). Results Compared to the control group, pSS patients demonstrated higher MG loss in both UL (33.8±13.2% vs. 24.4±8.5%, p< 0.01) and LL (52.5±15.7% vs. 43.0±9.6%, p<0.05), as well as higher lid abnormality score (0.8±0.8 vs. 0.2±0.6, p< 0.01). Furthermore, pSS patients showed higher OSDI and McMonnies questionnaire scores, elevated osmolarity, shorter TBUT, shorter blink interval, less wetting in Schirmer I test, more ocular surface staining and more corneal staining. MG loss in UL correlated negatively with TBUT (r = -0.386, p = 0.029) in the pSS group, whereas MG loss in LL correlated negatively with TBUT (r = -0.380, p = 0.035) in the control group. Conclusions Significantly elevated dry eye symptoms and signs were found in the pSS group compared with the control group, which might be attributed to both decreased aqueous tear production and increased tear evaporation

Meibomian Gland Morphology is a Sensitive Early Indicator of Meibomian Gland Dysfunction

Purpose To investigate the relationship between meibomian gland (MG) morphology and clinical dry eye tests in patients with meibomian gland dysfunction (MGD). Design Cross-sectional study. Subjects Total 538 MGD patients and 21 healthy controls. Methods MG loss on meibography images of upper (UL) and lower lids (LL) was graded on a scale of 0 (lowest degree of MG loss) to 3. MG length, thickness, and interglandular space in the UL were measured. Clinical tests included meibum expression and quality, tear film break-up time, ocular staining, osmolarity, Schirmer I, blink interval timing, and Ocular Surface Disease Index (OSDI) questionnaire. Results Mean UL and LL meibogrades were significantly higher in MGD patients compared to controls (P < .001 for UL and LL). The sensitivity and specificity of the meibograde as a diagnostic parameter for MGD was 96.7% and 85%, respectively. Schirmer I was significantly increased in MGD patients with meibograde 1 compared to patients with meibograde 0, 2, and 3 in the UL (P < .05). MG thickness increased with higher meibograde (P < .001). MG morphology correlated significantly but weakly with several clinical parameters (P < .05). OSDI did not correlate with any MG morphologic parameter. Conclusions Grading of MG loss using meibograde effectively diagnoses MGD. Compensatory mechanisms such as increased aqueous tear production and dilation of MGs make early detection of MGD difficult by standard clinical measures of dry eye, whereas morphologic analysis of MGs reveals an early stage of MGD, and therefore represents a complementary clinical parameter with diagnostic potential