How to create a successful mobile learning strategy for medical education during lockdowns?

BACKGROUND

Mobile learning has played an important role during the COVID-19 pandemic and medical schools now consider it as an effective educational method in current and future crises. In this qualitative study, an attempt was made to demonstrate the principles of designing a mobile learning strategy in medical education from the perspective of experts.

MATERIALS AND METHODS

The study was conducted by the qualitative content analysis method. The data were collected from July 2022 to Feb 2023. Twelve participants were included in this study from Iran's medical universities, consisting of two members of the Higher Council of Virtual Education, three educational directors, three clinical faculty members, two faculty members specializing in e-learning and medical education, an educational vice, and a dean. Data were collected using semi-structured interviews and analyzed by Granheim and Lundman's (2004) method.

RESULTS

Out of twelve participants in the study, eight (66%) were males and four (44%) females. Data were classified into eight categories and one theme. Based on the participants' experiences, the main theme, that is, "the principles of medical education design in mobile learning," included pedagogical component, interactive design, effective and comprehensive analysis, achieving objectives with the mobile learning platform, generating micro- and interactive e-content, teaching-learning interactive methods, course implementation and interactive evaluation at both micro- and macro-levels.

CONCLUSION

Data analysis revealed that in addition to the eight principles in the medical education design in mobile learning, the participants prioritized the two principles of pedagogical component and interactive design over other principles in educational design. Using a successful mobile learning strategy in situations of restrictions limiting physical presence may improve the quality of medical education.

Preparation of endothelial keratoplasty lamellae from donated whole eyes post vitreous humour aspiration at the central eye bank of Iran

To compare the endothelial parameters and thickness profiles of endothelial keratoplasty (EK) lamellae from donated whole eyes post vitreous humour aspiration (VHA) with those prepared from their mate control eyes (without VHA). Between March 2019 and March 2020, a few steps were added when aspirating the vitreous humour and also before dissecting the corneal tissue with microkeratome. EK lamellae were prepared from whole eyes that underwent VHA and their corresponding endothelial and thickness profiles were compared with those prepared from their respective fellow control eyes. Post-operative data in terms of graft attachment and clarity and the rate of reoperation were also reviewed. 115 eyes that underwent VHA and 115 of their respective fellow eyes were enrolled. No significant difference was noted in the endothelial parameters between the two groups. Mean central thickness of the EK lamellae and increase of thickness towards the periphery were not significantly different between the groups. Both groups did not show a significant difference with respect to the anticipated dissection depth, post-operative graft clarity, graft attachment, and the rate of regraft. This study demonstrates that aspirating vitreous humour has no adverse effect on the endothelial and thickness profiles of the EK lamellae that are prepared from these donated whole eyes, once the specific steps outlined by the eye bank are adhered to when aspirating the vitreous humor before performing the microkeratome dissection. The success rate of the grafted lamellae was comparable between the study groups.

The impact of non-coding RNAs in the pathobiology of eye disorders

Eye disorders are common disorders with significant effects on personal, economic, and social aspects of life. These disorders have a genetic background and are associated with dysregulation of non-coding RNAs. Three classes of these transcripts, namely long non-coding RNAs (lncRNAs), circular RNAs (circRNAs) and microRNAs (miRNAs) have established roles in the regulation of gene expression and pathoetiology of ocular disorders. H19, MEG3, BANCR, UCA1, HOTAIR, ANRIL, XIST and MIAT are among important lncRNAs in ocular disorders. CircRNAs from ZBTB44, HIPK3, circ-PSEN1, COL1A2, ZNF532 and FAM158A loci have also been found to affect pathoetiology of ocular disorders. Both lncRNAs and circRNAs can serve as molecular sponges for miRNAs. In this review, we searched PubMed and Google Scholar databases to find the research articles summarizing the impact of non-coding RNAs in ocular disorders. The results of these studies would help in identification of suitable targets for treatment of ocular disorders.

Prevalence of Meibomian Gland Dysfunction and Its Determinants in a Deprived Rural Population of Iran: A Population-Based Cross-Sectional Study

To investigate the prevalence of Meibomian gland dysfunction (MGD) and its relationship with some determinants in underserved villages of Iran. This population-based cross-sectional study was conducted on 3850 subjects that were randomly selected from the villages of two underserved districts in the north and southwest of Iran using multistage cluster sampling. All participants underwent complete ophthalmic examinations, including visual acuity and refraction measurement. Then, slit-lamp biomicroscopy was done by an ophthalmologist to investigate MGD. Of 3850 subjects that were invited, 3314 participated in the study (participation rate=86.07%), of whom 1834 (55.34%) were women. The mean age of the participants was 37.7±21.4 years (range=2-93 years). The prevalence (95% CI) of MGD in at least one eye was 29.20% (27.35 to 31.06). According to the results of multiple regression analysis, MGD had a positive association with the male sex (OR: 1.75; CI 95%: 1.44 to 2.13), age 61-70 years (OR: 7.15; CI 95%: 3.65 to 14.01), and living in southern villages (OR: 1.82; CI 95%: 1.48 to 2.22) and an inverse association with education level (OR: 0.89; CI 95%: 0.80 to 0.98). The results of this study showed a lower prevalence of MGD even in Iranian rural regions compared to other Asian countries. This study found that older age, male sex, and low education level served as MGD risk factors. It seems that improved health conditions are an important factor in preventing MGD.

Astigmatism profile in the elderly population: Tehran Geriatric Eye Study

PURPOSE

To determine the prevalence of astigmatism and its associated factors and examine astigmatism symmetry patterns in an elderly population.

STUDY DESIGN

Population based cross-sectional study.

METHODS

The present population-based cross-sectional study was conducted on an elderly population above 60 years of age in Tehran, Iran in 2019. The sampling was done using the stratified multistage random cluster sampling method. All study participants underwent a complete optometric examination and slit-lamp biomicroscopy.

RESULTS

The prevalence of astigmatism higher than -0.50, -1.00, and -2.00 D was 83% (95% CI: 81 -84), 52 % (95% CI: 50 -54), and 19% (95% CI: 17-20), respectively. These prevalence was 79%(95% CI: 77-81), 46(95% CI: 44-49) and 14(95% CI: 13-16) in subjects without a history of ocular surgery, respectively. Based on cylinder power worse than -1.00 D, 10% (95% CI: 9-12), 20% (95% CI: 18-22), and 21% (95% CI:19-23) of study participants had with the rule, against the rule, and oblique astigmatism, respectively. According to the results of the multiple regression model, male gender, older age, low education level, pure posterior subcapsular cataract, pseudophakia, and myopia were independent factors associated with astigmatism. The prevalence of anisorule astigmatism was 57 % (95% CI: 56-59), the most common anisorule astigmatism was against the rule-oblique type with a prevalence of 36% (95% CI: 34-38).

CONCLUSION

The prevalence of astigmatism was high in the elderly population of Tehran. More than half of the participants in this study had anisorule astigmatism, and against the rule-oblique combination was more prevalent than other types. A posterior subcapsular cataract, a history of cataract surgery, and myopia were the associated factors of astigmatism in this study.

Topography versus non-topography-guided photorefractive keratectomy with corneal cross-linking variations in keratoconus

AIM: To compare the visual results of non-topography-guided and topography-guided photorefractive keratectomy (PRK) applying sequential and simultaneous corneal cross-linking (CXL) treatment for keratoconus. METHODS: Interventional and comparative prospective study. Sixty-nine eyes (36 patients) suffering from keratoconus (stages 1 Amsler-Krumeich classification) were divided into four groups: sequential topography-guided photorefractive keratectomy with CXL, simultaneous topography-guided photorefractive keratectomy with CXL, simultaneous non-topography guided photorefractive keratectomy with CXL, and sequential non-topography guided photorefractive keratectomy with CXL. The main outcome measures were pre- and postoperative uncorrected distance visual acuity (UDVA), best corrected distance visual acuity (CDVA), manifest refraction, contrast sensitivity, and keratometry. RESULTS: All analyzed visual, contrast sensitivity, and refractive parameters showed a significant improvement in the four groups (all P<0.05). A noticeable improvement was seen in keratometry in all the groups, and a remarkable difference was observed between topography-guided groups in comparison to non-topography-guided groups (P<0.05). Interestingly, the improvement in all parameters showed a degree of stability to the end of the follow-up. CONCLUSION: The treatment priorities in all four groups are safety, efficacy, and predictability in the correction of the sphero-cylindrical errors in mild and moderate keratoconus. No significant differences among groups in the recorded objective outcomes were found.

Age and Sex Standardized Prevalence of Corneal Opacity and Its Determinants; Tehran Geriatric Eye Study (TGES)

Background:

We aimed to determine the age and sex standardized prevalence of corneal opacity and its determinants

Methods:

The Tehran Geriatric Eye Study (TGES) is a population-based cross-sectional study conducted on 3791 subjects aged above 60 yr in Tehran, Iran (2019) selected using stratified random cluster sampling. After sampling, all subjects underwent complete ophthalmic, optometric, and eye examinations.

Results:

The 3310 participated in the study, of whom the data of 3284 were analyzed. The age and sex standardized prevalence with 95% confidence interval (CI) of corneal opacity in at least one eye, both eyes, and one eye was 9.58% (95% CI: 8.50 to 10.79), 5.52% (95% CI: 4.71 to 6.45), and 4.07% (95% CI: 3.35 to 4.94), respectively. The mean uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) according to LogMar were worse in subjects with corneal opacity (both P<0.001). According to multiple logistic regression analysis, male sex (OR: 1.98; P: 0.003), age>80 yr (OR: 2.05; P: 0.004), and lack of insurance coverage (OR: 1.87; P: 0.004) increased the odds and high school education (OR: 0.68; P: 0.003) reduced the odds of corneal opacity. Among the study variables, sex was the most important determinant of corneal opacity (standardized beta: 0.126).

Conclusion:

This study found a high prevalence of corneal opacity in the geriatric population. Considering the increasing trend of population aging in Iran, attention should be paid to prioritizing public health policies to estimate resources required for providing comprehensive corneal services and improving geriatric eye health.

Anterior and posterior corneal higher-order aberrations in early diagnosis and grading of keratoconus

CLINICAL RELEVANCE

Evaluation of corneal higher-order aberrations can be used clinically to diagnose early cases of keratoconus as well as to classify the severity of keratoconus.

BACKGROUND

To investigate the anterior and posterior corneal higher-order aberrations (HOAs) up to the sixth order and their ability to identify early keratoconus (KCN) as well as differentiate different severities of KCN using cross-validation analysis.

METHODS

This prospective cross-sectional comparative study was performed at a tertiary eye hospital in Tehran, Iran, in 2019. The study sample consisted of 95 eyes of 95 patients with KCN and 53 eyes of 53 normal individuals. The eyes with KCN were classified into three groups based on the Amsler-Krumeich classification system: group 1 (mild KCN), group 2 (moderate KCN), and group 3 (severe KCN). Corneal wavefront analysis was performed using Pentacam HR.

RESULTS

Based on the magnitude of AUC, posterior vertical secondary coma (Z5^-1) had an excellent discriminant ability (AUC: 0.91) and anterior vertical coma (Z3^-1) and anterior vertical secondary coma (Z5^-1) had a good discriminant ability (0.8 < AUC < 0.89) for differentiating eyes with mild KCN from normal eyes. The anterior and posterior primary spherical aberrations (Z4°) had an excellent ability (AUC > 0.9), and anterior secondary spherical aberration (Z6°) had a good ability (AUC: 0.83) for differentiating moderate from mild KCN. In the differentiation of severe from moderate KCN, anterior and posterior primary aspherical aberrations (Z4°) had a good AUC value (AUC > 0.8).

CONCLUSION

Coma-like aberrations had a good discriminant ability between normal eyes and eyes with mild KCN. Spherical aberrations showed a good ability for differentiating between different stages of KCN. The cut-off values reported in this study can be used for early detection of KCN as well as classification of KCN severity.

Distance learning strategies in medical education during COVID-19: A systematic review

The current outbreak of coronavirus disease 2019 (COVID-19) across the world forced universities to suspend learning to limit the spread of the virus. Many medical schools have shifted to online education as an information delivery mechanism where the educator and learner are separated in space and potentially also in time. This systematic review aims to explore and understand the variety of distance learning strategies in medical students in the contexts of COVID-19. A systematic review was conducted in Web of Sciences, PubMed, Educational Resources and Information Center, and Scopus from December 2019 to July 2020. Eight sets of terminology were used, combining "Distance learning" AND "Medical education" AND "Pandemic." Studies were reviewed independently by two reviewers. Data were extracted and quality appraised using QualSyst tools, and synthesized by performing thematic analysis. A total of 473 articles were identified after removing duplicates and 314 records were screened, of which 125 were included in this study. The primary articles were 52 primarily qualitative articles. Five learning strategies consisted of technology-enhanced learning (TEL), simulation-based learning, technology-based clinical education, mobile learning, and blended learning. Tools, methods, and learning resources associated with these five learning strategies were extracted from the articles. Our review highlights that TEL and simulation-based learning were more commonly used than others in distance learning in medical education during the COVID-19 pandemic. These strategies have the potential to improve learners' level of knowledge and performance through making online learning resources such as Massive Open Online Courses, virtual clinical cases, and blended sources accessible.

Ocular findings in patients with psoriasis: is it related to the side effects of treatment or to psoriasis itself? A case-control study

Objectives: To assess ocular abnormalities in psoriatic patients (new-cases versus patients under treatment) in comparison with healthy controls.Methods: A total of 200 psoriatic patients and 100 healthy controls were enrolled in this prospective, observational study. The demographic data of the individuals were recorded. Dermatological and ophthalmologic examinations were conducted; ocular surface disease index (OSDI), Schirmer's and tear break-up time (TBUT) values were also measured.Results: The mean values of TBUT and Schirmer's tests in patients were significantly lower than the controls and significantly higher scores of OSDI were observed among patients compared to the controls (p < .0001); dry eye disease was more frequent in the patients than the healthy subjects (p = .001). Other ocular findings including cataract and uveitis were not significantly different between the groups. Although no significant differences were found between the ocular findings of new cases and patients under treatment, ocular findings in cases under treatment were associated with the type of treatment and more frequent in those treated with methotrexate, followed by acitretin and biologic drugs.Conclusions: Ocular surface problems in psoriatic patients are more common than previously thought; in addition to the role of treatment modalities, psoriasis itself and a probable systemic inflammation may play an important role.Key PointsThere are limited case-control studies about ocular manifestations in psoriasis and also its pathogenesis is not yet clear.This study shows that ocular surface problems in psoriatic patients are higher than healthy subjects; in addition to the role of treatment modalities, psoriasis itself and a probable systemic inflammation may play a pivotal role.Regular ophthalmological evaluations are recommended in psoriatic patients especially those with more severe and chronic form of the disease, to prevent any complications.

Sulfur Mustard-Induced Ocular Injuries: Update on Mechanisms and Management

Sulfur mustard (SM; mustard gas) is a classic chemical warfare agent that has been used in several wars and is still a potential threat especially in the Middle-East region. Victims experience acute symptoms in airexposed organs including skin, respiratory tract and the eyes. Survivors of the acute stage might develop chronic or delayed-onset complications in the exposed organs. The exact mechanism(s) of SM-induced tissue damage is still unknown, however DNA alkylation and oxidative damage are the most relevant mechanisms. Eye is the most sensitive organ to the SM vapor and ocular symptoms usually precede other manifestations. Ocular findings including blepharitis, dry eye disease, corneal vascularization, persistent epithelial defects, limbal ischemia, limbal stem cell deficiency, corneal thinning, corneal opacity and corneal innervation abnormalities have been reported several years after SM exposure. In this review, mechanisms of acute and chronic/delayed ocular manifestations of SM and their current management and potential future therapies have been discussed. We have also included recent advances in amniotic membrane transplantation, cultivated stem cell transplantation and anti-angiogenic therapies which might be considered as therapeutic options in SM-induced ocular damage in the future.

Accelerated versus conventional corneal collagen cross-linking in patients with keratoconus: an intrapatient comparative study

PURPOSE

To compare the outcomes of the conventional and accelerated corneal collagen cross-linking (CXL) in patients with bilateral progressive keratoconus (KC).

METHODS

Fifteen consecutive patients with bilateral progressive KC were enrolled. In each patient, the fellow eyes were randomly assigned to the conventional CXL (3 mW/cm² for 30 min) or accelerated CXL (ACXL) (9 mW/cm² for 10 min) groups. Manifest refraction; uncorrected and corrected distant visual acuity; maximum and mean keratometry; corneal hysteresis and corneal resistance factor; endothelial cell density and morphology; central corneal thickness; and wavefront aberrations were measured before and 12 months after the CXL.

RESULTS

Manifest refraction spherical equivalent and refractive cylinder improved significantly only in conventional group. Uncorrected and corrected distant visual acuity did not change significantly in either group. Also there was no significant change in the maximum and mean keratometry after 12 months. There was significant decrease in central corneal thickness in both groups which was more prominent in conventional group. Endothelial cell density reduced only in the conventional group which was not statistically significant (P = 0.147). CH, CRF, and wavefront aberrations did not change significantly in either group. We did not observe any significant difference in the changes of the variables between the two groups.

CONCLUSIONS

Accelerated CXL with 9 mW/cm² irradiation for 10 min had similar refractive, visual, keratometric, and aberrometric results and less adverse effects on the corneal thickness and endothelial cells as compared with the conventional method after 12 months follow-up. However, randomized clinical trials with longer follow-ups and larger sample sizes are needed.

Visual and Refractive Outcomes of Phacoemulsification with Implantation of Accommodating versus Standard Monofocal Intraocular Lenses

Purpose:

To compare distant and near visual function after cataract surgery with implantation of Crystalens HD or Tek-Clear as accommodating intraocular lenses (IOLs), versus SA60AT as a standard IOL.

Methods:

The study included 62 eyes of 58 patients divided into three groups using three different IOLs: Crystalens HD (Bausch and Lomb, NY, USA), Tek-Clear (Tekia, CA, USA) and SA60AT (Alcon, TX, USA) were implanted in 23, 14 and 25 eyes, respectively. Corrected distant visual acuity (CDVA), uncorrected and distance corrected near visual acuities (UCNVA and DCNVA), near point of accommodation (NPA), spectacle freedom and patient satisfaction were assessed six months postoperatively and compared between the three groups.

Results:

After 6 months, all patients showed significant improvement in CDVA with no significant difference among the study groups. However, UCNVA and DCNVA were significantly better in patients implanted with accommodating IOLs. NPA was closest in the Crystalens HD group, followed by Tek-Clear and monofocal SA60AT (P < 0.001). Patients with accommodating IOLs were more likely to become spectacle free and satisfied with their near vision as compared to subjects receiving a monofocal IOL.

Conclusions:

Accommodating IOLs (Crystalens HD and Tek-Clear) effectively reduce the necessity for spectacles after cataract surgery.

Corneal Changes After Collagen Crosslinking for Keratoconus Using Dual Scheimpflug Imaging

Purpose:

To evaluate corneal changes after collagen crosslinking (CXL) therapy for keratoconus (KCN) using the Galilei dual Scheimpflug analyzer.

Methods:

This prospective, nonrandomized clinical study included 35 eyes of 32 keratoconus patients who had undergone CXL. The eyes were saturated with riboflavin solution and were subjected for 30 minutes to ultraviolet-A (UV-A) light with irradiance of 3 mW/cm². Effectiveness of the treatment was assessed by measuring uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest cylinder/sphere, keratometry, pachymetry, posterior and anterior elevations by the Galilei dual Scheimpflug analyzer. Prior to treatment and 8 months after therapy, Scheimpflug analysis was performed using the Galilei system. The four sets of data including keratometry values, pachymetry, elevation parameters and surface indices were statistically analyzed and compared.

Results:

Mean patient age was 22.3 ± 3.8 years and mean postoperative follow-up was 8.1 ± 3.2 months. There was a significant increase in UCVA (0.54 ± 0.35 Log MAR preoperatively to 0.49 ± 0.34 LogMAR postoperatively, P = 0.01) and BCVA (0.21 ± 0.19 Log MAR preoperatively to 0.16 ± 0.17 LogMAR postoperatively, P = 0.01). Mean cycloplegic spherical equivalent refractive error was −4.13 ± 2.65 Diopter (D) preoperatively and − 4.67 ± 2.96 D postoperatively (P < 0.001). During the follow-up period, no significant difference was observed in pachymetric and elevation data postoperatively.

Conclusion:

Corneal stabilization could be achieved by collagen crosslinking therapy for keratoconus in terms of corneal thickness, keratometry values, elevation parameters and surface indices.

Measurement of Central Corneal Thickness Using Ultrasound Pachymetry and Orbscan II in Normal Eyes

Purpose:

To compare ultrasound pachymetry and Orbscan II for measurement of central corneal thickness (CCT) in normal eyes.

Methods:

The current study was performed at Labbafinejad Medical Center (LMC), Tehran, Iran. Three hundred eyes from 150 healthy individuals referred for keratorefractive surgery were assessed first by Orbscan II and then by ultrasound pachymetry, and CCT values were recorded and compared.

Results:

Overall, Orbscan II overestimated CCT as compared to ultrasound pachymetry by about 2.4% (mean values 547.6 ± 34.7 versus 534.8 ± 34.7, respectively, P < 0.001). The difference was more significant when CCT was less than 500 microns (mean values 493.2 ± 16.9 versus 479.9 ± 15.6, mean overestimation: 2.6%, P < 0.001). There was good linear correlation between the two methods (Pearson's correlation r = 0.968, P < 0.0001).

Conclusion:

Orbscan II has good correlation with ultrasound pachymetry for measurement of CCT in normal eyes; however Orbscan II should not be used to evaluate corneal thickness before keratorefractive surgeries, as it tends to overestimate corneal thickness and may result in undesirable, low residual stromal thickness.