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Cabrera-Aguas M, Watson SL. Updates in Diagnostic Imaging for Infectious Keratitis: A Review. Diagnostics (Basel) 2023; 13:3358. [PMID: 37958254 PMCID: PMC10647798 DOI: 10.3390/diagnostics13213358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/15/2023] Open
Abstract
Infectious keratitis (IK) is among the top five leading causes of blindness globally. Early diagnosis is needed to guide appropriate therapy to avoid complications such as vision impairment and blindness. Slit lamp microscopy and culture of corneal scrapes are key to diagnosing IK. Slit lamp photography was transformed when digital cameras and smartphones were invented. The digital camera or smartphone camera sensor's resolution, the resolution of the slit lamp and the focal length of the smartphone camera system are key to a high-quality slit lamp image. Alternative diagnostic tools include imaging, such as optical coherence tomography (OCT) and in vivo confocal microscopy (IVCM). OCT's advantage is its ability to accurately determine the depth and extent of the corneal ulceration, infiltrates and haze, therefore characterizing the severity and progression of the infection. However, OCT is not a preferred choice in the diagnostic tool package for infectious keratitis. Rather, IVCM is a great aid in the diagnosis of fungal and Acanthamoeba keratitis with overall sensitivities of 66-74% and 80-100% and specificity of 78-100% and 84-100%, respectively. Recently, deep learning (DL) models have been shown to be promising aids for the diagnosis of IK via image recognition. Most of the studies that have developed DL models to diagnose the different types of IK have utilised slit lamp photographs. Some studies have used extremely efficient single convolutional neural network algorithms to train their models, and others used ensemble approaches with variable results. Limitations of DL models include the need for large image datasets to train the models, the difficulty in finding special features of the different types of IK, the imbalance of training models, the lack of image protocols and misclassification bias, which need to be overcome to apply these models into real-world settings. Newer artificial intelligence technology that generates synthetic data, such as generative adversarial networks, may assist in overcoming some of these limitations of CNN models.
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Affiliation(s)
- Maria Cabrera-Aguas
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2000, Australia;
- Sydney Eye Hospital, Sydney, NSW 2000, Australia
| | - Stephanie L Watson
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2000, Australia;
- Sydney Eye Hospital, Sydney, NSW 2000, Australia
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Ung L, Chodosh J. Urgent unmet needs in the care of bacterial keratitis: An evidence-based synthesis. Ocul Surf 2023; 28:378-400. [PMID: 34461290 PMCID: PMC10721114 DOI: 10.1016/j.jtos.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/21/2022]
Abstract
Bacterial corneal infections, or bacterial keratitis (BK), are ophthalmic emergencies that frequently lead to irreversible visual impairment. Though increasingly recognized as a major cause of global blindness, modern paradigms of evidence-based care in BK have remained at a diagnostic and therapeutic impasse for over half a century. Current standards of management - based on the collection of corneal cultures and the application of broad-spectrum topical antibiotics - are beset by important yet widely underrecognized limitations, including approximately 30% of all patients who will develop moderate to severe vision loss in the affected eye. Though recent advances have involved a more clearly defined role for adjunctive topical corticosteroids, and novel therapies such as corneal crosslinking, overall progress to improve patient and population-based outcomes remains incommensurate to the chronic morbidity caused by this disease. Recognizing that the care of BK is guided by the clinical axiom, "time equals vision", this chapter offers an evidence-based synthesis for the clinical management of these infections, underscoring critical unmet needs in disease prevention, diagnosis, and treatment.
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Affiliation(s)
- Lawson Ung
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
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Woods C, Naroo S, Zeri F, Bakkar M, Barodawala F, Evans V, Fadel D, Kalikivayi L, Lira M, Maseedupally V, Huarte ST, Eperjesi F. Evidence for commonly used teaching, learning and assessment methods in contact lens clinical skills education. Cont Lens Anterior Eye 2023; 46:101821. [PMID: 36805277 DOI: 10.1016/j.clae.2023.101821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Evidence based practice is now an important part of healthcare education. The aim of this narrative literature review was to determine what evidence exists on the efficacy of commonly used teaching and learning and assessment methods in the realm of contact lens skills education (CLE) in order to provide insights into best practice. A summary of the global regulation and provision of postgraduate learning and continuing professional development in CLE is included. METHOD An expert panel of educators was recruited and completed a literature review of current evidence of teaching and learning and assessment methods in healthcare training, with an emphasis on health care, general optometry and CLE. RESULTS No direct evidence of benefit of teaching and learning and assessment methods in CLE were found. There was evidence for the benefit of some teaching and learning and assessment methods in other disciplines that could be transferable to CLE and could help students meet the intended learning outcomes. There was evidence that the following teaching and learning methods helped health-care and general optometry students meet the intended learning outcomes; clinical teaching and learning, flipped classrooms, clinical skills videos and clerkships. For assessment these methods were; essays, case presentations, objective structured clinical examinations, self-assessment and formative assessment. There was no evidence that the following teaching and learning methods helped health-care and general optometry students meet the intended learning outcomes; journal clubs and case discussions. Nor was any evidence found for the following assessment methods; multiple-choice questions, oral examinations, objective structured practical examinations, holistic assessment, and summative assessment. CONCLUSION Investigation into the efficacy of common teaching and learning and assessment methods in CLE are required and would be beneficial for the entire community of contact lens educators, and other disciplines that wish to adapt this approach of evidence-based teaching.
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Affiliation(s)
- Craig Woods
- School of Optometry and Vision Science, University of New South Wales, Australia; International Association of Contact Lens Educators, Canada
| | - Shehzad Naroo
- College of Health and Life Sciences, Aston University, UK; International Association of Contact Lens Educators, Canada
| | - Fabrizio Zeri
- College of Health and Life Sciences, Aston University, UK; University of Milano-Bicocca, Department of Materials Science, Milan, Italy; International Association of Contact Lens Educators, Canada
| | - May Bakkar
- Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Jordan
| | - Fakhruddin Barodawala
- Faculty of Optometry and Vision Sciences, SEGi University, Malaysia; International Association of Contact Lens Educators, Canada
| | - Vicki Evans
- Faculty of Health, University of Canberra, Australia; International Association of Contact Lens Educators, Canada
| | - Daddi Fadel
- Center for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Canada
| | | | - Madalena Lira
- Physics Center of Minho and Porto Universities (CF-UM-UP), School of Sciences, University of Minho, Portugal; International Association of Contact Lens Educators, Canada
| | - Vinod Maseedupally
- School of Optometry and Vision Science, University of New South Wales, Australia
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Srinivasa K, Moir F, Goodyear-Smith F. The Role of Online Videos in Teaching Procedural Skills in Postgraduate Medical Education: A Scoping Review. JOURNAL OF SURGICAL EDUCATION 2022; 79:1295-1307. [PMID: 35725724 DOI: 10.1016/j.jsurg.2022.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/27/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The purpose of this scoping review was to outline the extent of available literature including the prevalence of video quality appraisal tools, characterize how online videos were used, and identify the gaps in the literature with implications for future research. DESIGN The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews (PRISMA-ScR). Six databases were searched: (1) MEDLINE (Ovid), (2) EMBASE, (3) Cochrane, (4) ERIC, (5) CINAHL PLUS, and (6) Google Scholar for Medical Subject Headings terms online videos, postgraduate health education, and health professional/s. RESULTS A total of 6948 articles were identified, of which 78 were included in the review. The articles included were primarily either experimental or observational studies, with most being from North America. Twelve concepts were identified: (1) procedural skills teaching; (2) video assessment; (3) validation of an assessment tool; (4) video feedback; (5) coaching; (6) broadcasting; (7) learner characteristics; (8) video characteristics; (9) video quality; (10) a quality assessment tool; (11) platforms and video library; and (12) health information governance. CONCLUSIONS While there is a diverse and growing body of literature on this area, information is lacking about the quality appraisal of online videos.
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Affiliation(s)
- Komal Srinivasa
- Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand.
| | - Fiona Moir
- Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Felicity Goodyear-Smith
- Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand
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Cabrera‐Aguas M, Khoo P, Watson SL. Infectious keratitis: A review. Clin Exp Ophthalmol 2022; 50:543-562. [PMID: 35610943 PMCID: PMC9542356 DOI: 10.1111/ceo.14113] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 12/29/2022]
Abstract
Globally, infectious keratitis is the fifth leading cause of blindness. The main predisposing factors include contact lens wear, ocular injury and ocular surface disease. Staphylococcus species, Pseudomonas aeruginosa, Fusarium species, Candida species and Acanthamoeba species are the most common causal organisms. Culture of corneal scrapes is the preferred initial test to identify the culprit organism. Polymerase chain reaction (PCR) tests and in vivo confocal microscopy can complement the diagnosis. Empiric therapy is typically commenced with fluoroquinolones, or fortified antibiotics for bacterial keratitis; topical natamycin for fungal keratitis; and polyhexamethylene biguanide or chlorhexidine for acanthamoeba keratitis. Herpes simplex keratitis is mainly diagnosed clinically; however, PCR can also be used to confirm the initial diagnosis and in atypical cases. Antivirals and topical corticosteroids are indicated depending on the corneal layer infected. Vision impairment, blindness and even loss of the eye can occur with a delay in diagnosis and inappropriate antimicrobial therapy.
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Affiliation(s)
- Maria Cabrera‐Aguas
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Corneal Unit Sydney Eye Hospital Sydney New South Wales Australia
| | - Pauline Khoo
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Corneal Unit Sydney Eye Hospital Sydney New South Wales Australia
| | - Stephanie L. Watson
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
- Corneal Unit Sydney Eye Hospital Sydney New South Wales Australia
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Tuft S, Somerville TF, Li JPO, Neal T, De S, Horsburgh MJ, Fothergill JL, Foulkes D, Kaye S. Bacterial keratitis: identifying the areas of clinical uncertainty. Prog Retin Eye Res 2021; 89:101031. [PMID: 34915112 DOI: 10.1016/j.preteyeres.2021.101031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022]
Abstract
Bacterial keratitis is a common corneal infection that is treated with topical antimicrobials. By the time of presentation there may already be severe visual loss from corneal ulceration and opacity, which may persist despite treatment. There are significant differences in the associated risk factors and the bacterial isolates between high income and low- or middle-income countries, so that general management guidelines may not be appropriate. Although the diagnosis of bacterial keratitis may seem intuitive there are multiple uncertainties about the criteria that are used, which impacts the interpretation of investigations and recruitment to clinical studies. Importantly, the concept that bacterial keratitis can only be confirmed by culture ignores the approximately 50% of cases clinically consistent with bacterial keratitis in which investigations are negative. The aetiology of these culture-negative cases is unknown. Currently, the estimation of bacterial susceptibility to antimicrobials is based on data from systemic administration and achievable serum or tissue concentrations, rather than relevant corneal concentrations and biological activity in the cornea. The provision to the clinician of minimum inhibitory concentrations of the antimicrobials for the isolated bacteria would be an important step forward. An increase in the prevalence of antimicrobial resistance is a concern, but the effect this has on disease outcomes is yet unclear. Virulence factors are not routinely assessed although they may affect the pathogenicity of bacteria within species and affect outcomes. New technologies have been developed to detect and kill bacteria, and their application to bacterial keratitis is discussed. In this review we present the multiple areas of clinical uncertainty that hamper research and the clinical management of bacterial keratitis, and we address some of the assumptions and dogma that have become established in the literature.
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Affiliation(s)
- Stephen Tuft
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK.
| | - Tobi F Somerville
- Department of Eye and Vision Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | - Ji-Peng Olivia Li
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK.
| | - Timothy Neal
- Department of Clinical Microbiology, Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK.
| | - Surjo De
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK.
| | - Malcolm J Horsburgh
- Department of Infection and Microbiomes, University of Liverpool, Crown Street, Liverpool, L69 7BX, UK.
| | - Joanne L Fothergill
- Department of Eye and Vision Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | - Daniel Foulkes
- Department of Eye and Vision Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | - Stephen Kaye
- Department of Eye and Vision Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK.
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Hoffman JJ, Burton MJ, Leck A. Mycotic Keratitis-A Global Threat from the Filamentous Fungi. J Fungi (Basel) 2021; 7:273. [PMID: 33916767 PMCID: PMC8066744 DOI: 10.3390/jof7040273] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/16/2022] Open
Abstract
Mycotic or fungal keratitis (FK) is a sight-threatening disease, caused by infection of the cornea by filamentous fungi or yeasts. In tropical, low and middle-income countries, it accounts for the majority of cases of microbial keratitis (MK). Filamentous fungi, in particular Fusarium spp., the aspergilli and dematiaceous fungi, are responsible for the greatest burden of disease. The predominant risk factor for filamentous fungal keratitis is trauma, typically with organic, plant-based material. In developed countries, contact lens wear and related products are frequently implicated as risk factors, and have been linked to global outbreaks of Fusarium keratitis in the recent past. In 2020, the incidence of FK was estimated to be over 1 million cases per year, and there is significant geographical variation; accounting for less than 1% of cases of MK in some European countries to over 80% in parts of south and south-east Asia. The proportion of MK cases is inversely correlated to distance from the equator and there is emerging evidence that the incidence of FK may be increasing. Diagnosing FK is challenging; accurate diagnosis relies on reliable microscopy and culture, aided by adjunctive tools such as in vivo confocal microscopy or PCR. Unfortunately, these facilities are infrequently available in areas most in need. Current topical antifungals are not very effective; infections can progress despite prompt treatment. Antifungal drops are often unavailable. When available, natamycin is usually first-line treatment. However, infections may progress to perforation in ~25% of cases. Future work needs to be directed at addressing these challenges and unmet needs. This review discusses the epidemiology, clinical features, diagnosis, management and aetiology of FK.
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Affiliation(s)
- Jeremy J. Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (M.J.B.); (A.L.)
- Cornea Service, Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal
- Department of Ophthalmology, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (M.J.B.); (A.L.)
- National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (M.J.B.); (A.L.)
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Khoo P, Cabrera-Aguas M, Watson SL. Microbial Keratitis After Corneal Collagen Cross-Linking for Corneal Ectasia. Asia Pac J Ophthalmol (Phila) 2021; 10:355-359. [PMID: 33534235 DOI: 10.1097/apo.0000000000000379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The aim of this study was to report the clinical profile and microbiological of patients with microbial keratitis post accelerated corneal collagen cross-linking (CXL). METHODS A retrospective case series of all patients diagnosed with microbial keratitis post-CXL who attended the Sydney Eye Hospital, Australia from January 1, 2012 to December 31, 2019 were included. Patients were identified from hospital coding and pathology data. Data were extracted from patients' medical records. RESULTS Eleven eyes from 10 patients with a mean age of 29 ± 11 years (range 16-48) were included. The median time of infection after CXL surgery was 4 days [interquartile range (IQR) 3-83]. Median initial and final Visual acuity at presentation were 1.3 logMAR (IQR 1-2.0) and 0.8 logMAR (IQR 0.6-1.2), respectively. The culture positivity rate was 92%, identifying 13 isolates, predominately made up of coagulase-negative Staphylococcus (n = 6, 50%) and Staphylococcus aureus (n = 3, 25%). The median epithelial healing time was 30 days (IQR 15-53). CONCLUSIONS Post-CXL microbial keratitis was predominately associated with gram-positive bacteria and in some cases delayed epithelialization. Microbial keratitis post-CXL may lead to moderate to poor patient outcomes.
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Affiliation(s)
- Pauline Khoo
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
| | - Maria Cabrera-Aguas
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
| | - Stephanie L Watson
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
- Corneal Unit, Sydney Eye Hospital, Sydney, New South Wales, Australia
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Khoo P, Cabrera-Aguas M, Watson SL. Topical Steroids as Adjunctive Therapy for Bacterial Keratitis: Evidence From a Retrospective Case Series of 313 Cases. Asia Pac J Ophthalmol (Phila) 2020; 9:398-403. [PMID: 32956189 DOI: 10.1097/apo.0000000000000320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The aim of this study was to report topical steroid usage in bacterial keratitis and analyze the effects of steroids on patients' outcomes to the main causative organisms. DESIGN A retrospective case-series. METHODS This study included all patients with corneal scrape positive bacterial keratitis from January 2012 to December 2016 at the Sydney Eye Hospital, Sydney, Australia. Cases were identified from pathology results and hospital coding, and data collected from medical records. RESULTS A total of 313 eyes from 308 patients with a mean age of 51 years [interquartile range (IQR) 36-72] were included. Of these patients, 192 (61%) were treated with topical steroids. High-dose steroids were prescribed in 22 (11%) cases, regular-dose in 88 (46%), and low-dose in 82 (43%). The median time until the implementation of steroid use was 4 days (IQR 3-7). Patients prescribed with topical steroids had significantly longer healing times than the "no steroid" group (11 vs 6.5, P < 0.001). Patients with Pseudomonas aeruginosa keratitis and topical steroid use had worse clinical outcomes, with a higher proportion having longer healing times (P = 0.04) and corneal scarring (P = 0.02). CONCLUSIONS Adjuvant topical steroid therapy did not affect visual acuity, patient outcomes or the rate of adverse effects but may delay epithelial healing in bacterial keratitis in these patients. Topical steroids may have a differential effect depending on the specific causative organisms; however, a clinical trial is needed to assess this.
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Affiliation(s)
- Pauline Khoo
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
| | - Maria Cabrera-Aguas
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
| | - Stephanie L Watson
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
- Corneal Unit, Sydney Eye Hospital, Sydney, New South Wales, Australia
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