Colm McAlinden

The Burden of Primary Liver Cancer and Underlying Etiologies From 1990 to 2015 at the Global, Regional, and National Level: Results From the Global Burden of Disease Study 2015

Importance Liver cancer is among the leading causes of cancer deaths globally. The most common causes for liver cancer include hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and alcohol use. Objective To report results of the Global Burden of Disease (GBD) 2015 study on primary liver cancer incidence, mortality, and disability-adjusted life-years (DALYs) for 195 countries or territories from 1990 to 2015, and present global, regional, and national estimates on the burden of liver cancer attributable to HBV, HCV, alcohol, and an “other” group that encompasses residual causes. Design, Settings, and Participants Mortality was estimated using vital registration and cancer registry data in an ensemble modeling approach. Single-cause mortality estimates were adjusted for all-cause mortality. Incidence was derived from mortality estimates and the mortality-to-incidence ratio. Through a systematic literature review, data on the proportions of liver cancer due to HBV, HCV, alcohol, and other causes were identified. Years of life lost were calculated by multiplying each death by a standard life expectancy. Prevalence was estimated using mortality-to-incidence ratio as surrogate for survival. Total prevalence was divided into 4 sequelae that were multiplied by disability weights to derive years lived with disability (YLDs). DALYs were the sum of years of life lost and YLDs. Main Outcomes and Measures Liver cancer mortality, incidence, YLDs, years of life lost, DALYs by etiology, age, sex, country, and year. Results There were 854 000 incident cases of liver cancer and 810 000 deaths globally in 2015, contributing to 20 578 000 DALYs. Cases of incident liver cancer increased by 75% between 1990 and 2015, of which 47% can be explained by changing population age structures, 35% by population growth, and −8% to changing age-specific incidence rates. The male-to-female ratio for age-standardized liver cancer mortality was 2.8. Globally, HBV accounted for 265 000 liver cancer deaths (33%), alcohol for 245 000 (30%), HCV for 167 000 (21%), and other causes for 133 000 (16%) deaths, with substantial variation between countries in the underlying etiologies. Conclusions and Relevance Liver cancer is among the leading causes of cancer deaths in many countries. Causes of liver cancer differ widely among populations. Our results show that most cases of liver cancer can be prevented through vaccination, antiviral treatment, safe blood transfusion and injection practices, as well as interventions to reduce excessive alcohol use. In line with the Sustainable Development Goals, the identification and elimination of risk factors for liver cancer will be required to achieve a sustained reduction in liver cancer burden. The GBD study can be used to guide these prevention efforts.

Comparing accommodative function between the dominant and non-dominant eye.

BackgroundTo compare the accommodative amplitude (AA), facility (AF), and lag between dominant and non-dominant eyes.MethodsSeventy students [mean (SD) age: 21.2 (1.7) years, range 18–25] from Zahedan University of Medical Sciences were selected. Retinoscopy and subjective refraction was used to determine the refractive error. The hole-in-the card method was used to determine eye dominance. The accommodative amplitude (AA) was measured in the dominant and non-dominant eye using the push-up method, and accommodative facility (AF) using ±2.00 dioptre flipper lenses at 40xa0cm. Accommodative lag was determined using monocular estimate method (MEM) retinoscopy at 40xa0cm.ResultsThe right eye was dominant in 53 subjects (75.7xa0%). There was no significant difference in refractive error (sphere, cylinder, and spherical equivalent) between dominant and non-dominant eyes. The mean (SD) for the AA, AF, and lag in dominant eyes was 12.48 (2.56) dioptres, 12.45 (4.83) cycles per minute, and 0.80 (0.27) dioptres respectively. The mean (SD) for the AA, AF, and lag in non-dominant eyes was 12.16 (2.37) dioptres, 12.20 (4.88) cycles per minute, and 0.83 (0.28) dioptres respectively. The mean (SD) difference in AA, AF, and lag between dominant and non dominant eyes was 0.32 (0.75) dioptres (Pu2009=u20090.001), 0.25 (1.05) cycles per minute (Pu2009=u20090.04), and −0.02 (0.11) dioptres (Pu2009=u20090.10) respectively. The AA and AF was statistically better (Pu2009<u20090.05) in the dominant eye group than in the non-dominant eye group. These data provided little evidence of any difference in the accommodative lag between dominant and non-dominant eyes (Pu2009>u20090.05).ConclusionThe right eye was dominant in 76xa0% of subjects. Superior AA and AF was found in the dominant eye as determined by hole-in-the card method in young healthy adults, although these differences are perhaps not of clinical significance (<0.50 dioptres and <2xa0cycles per minute).

Giant cell arteritis

In July 2013, a 64-year-old woman presented to her optometrist with a 4-day history of intermittent blurred vision in the left eye with a left-sided headache. The patient was unsure whether she had had jaw claudication or scalp tenderness. She had no previous ocular history except spectacles for hyperopia and presbyopia. She had been taking diclofenac, tramadol, omeprazole, alendronic acid, calcium sup plements, and glyceryl trinitrate spray. Her best corrected visual acuity was 6/6 in the right eye and 6/60 in the left eye. Pupil reactions indicated a positive left relative aff erent pupillary defect. A swollen optic disc was observed in the left eye, more severe in the superior region with a corresponding inferior visual fi eld defect. The patient was referred urgently to the local eye casualty department with the working diagnosis of arteritic anterior ischaemic optic neuropathy secondary to giant cell arteritis. The patient attended the eye casualty department a few hours later and her vision had reduced further to hand movements. A fundus photograph showed a mildly swollen left disc (fi gure A). The left superfi cial temporal artery was pulsatile and tender. She was given aspirin 75 mg. Full blood count test results were all normal except for the red cell distribution width, which was slightly high at 15·3% (normal range 11·0–14·8). C-reactive protein was 7 mg/L (local laboratory normal range 0–10) and the erythrocyte sedimentation rate was 14 mm/h (local laboratory normal range 0–20). Urea and electrolytes, glucose, and liver function test results were all normal. Although the usual treatment for patients with giant cell arteritis is initial intravenous methylprednisolone for 3 days then switching to oral prednisolone, because of the slightly atypical presentation with normal infl ammatory markers in our patient, treatment with oral prednisolone 60 mg daily was chosen and a temporal artery biopsy was scheduled. The biopsy was done 5 days later and showed features consistent with giant cell arteritis (fi gure B, C). The patient did not develop any ocular problems in the right eye. Giant cell arteritis is a granulomatous arteritis with a propensity for medium and large sized arteries. Common symptoms include visual loss, headache, scalp tenderness, and jaw claudication. The visual consequence is usually arteritic anterior ischaemic optic neuropathy, although other manifestations can occur. The clinical signs of arteritic anterior ischaemic optic neuropathy include a reduction in visual acuity, relative aff erent pupillary defect, swollen optic disc with or without peripapillary haemorrhages and cotton wool spots. Other clinical features can include polymyalgia rheumatica, a thickened and tender non-pulsatile temporal artery, aneurysms, CNS disease, and stroke. Diagnosis is usually made on clinical suspicion, high erythrocyte sedimentation rate and C-reactive protein and histologically, via a temporal artery biopsy. A prompt diagnosis of giant cell arteritis is essential to reduce the risk of bilateral blindness. C-reactive protein and erythrocyte sedimentation rate infl ammatory markers will usually aid diagnosis but—as in this case—results can be within normal reference ranges in about 4% of patients. Erythrocyte sedimentation rate and C-reactive protein can be aff ected by many factors including drugs. Clinicians should be aware that a normal erythrocyte sedimentation rate and C-reactive protein does not rule out giant cell arteritis. If giant cell arteritis is suspected on clinical grounds, a temporal artery biopsy should be done irrespective of the erythrocyte sedi mentation rate and C-reactive protein values.

Through-Focus Vision Performance and Light Disturbances of 3 New Intraocular Lenses for Presbyopia Correction

Purpose To compare the through-focus visual performance in a clinical population of pseudophakic patients implanted with two new trifocal intraocular lenses (IOLs) and one extended depth of focus IOL. Methods Prospective, nonrandomized, examiner-masked case series. Twenty-three patients received the FineVision® and seven patients received the PanOptix™ trifocal IOLs. Fifteen patients received the Symfony extended depth of focus IOL. Mean age of patients was 63u2009±u20098 years. Through-focus visual acuity was measured from –3.00 to +1.00u2009D vergences. Contrast sensitivity was measured with and without a source of glare. Light disturbances were evaluated with the Light Distortion Analyzer. Results Though-focus evaluation showed that trifocal IOLs performed significantly better at near distance (33 and 40u2009cm), and extended depth of focus performed significantly better at intermediate distance (1.0u2009m). Contrast sensitivity function with glare and dysphotopsia was similar between the three IOLs and subjective response to questionnaire showed a significantly higher score (worse performance) for the extended depth of focus IOL compared to both trifocal IOLs in the bothersome subscale (p < 0.05). Conclusions Trifocal IOLs grant better performance at near distance while extended depth of focus IOL performs better at intermediate distance. Objective dysphotopsia measured with the Light Distortion Analyzer is not reduced in extended depth of focus IOL compared to trifocal IOLs.

Identifying more reliable parameters for the detection of change during the follow-up of mild to moderate keratoconus patients

BackgroundReaching a consensus on which parameters are most reliable at detecting progressive keratoconus patients with serial topography imaging is not evident. The aim of the study was to isolate the parameters best positioned to detect keratoconus progression using the Pentacam HR® measures based on the respective limits of repeatability and range of measurement.MethodUsing the Pentacam HR®, a tolerance index was calculated on anterior segment parameters in healthy and keratoconic eyes. The tolerance index provides a scale from least to most affected parameters in terms of measurement noise relative to that observed in healthy eyes. Then, based on the “number of increments” from no disease to advanced disease, a relative utility (RU) score was also calculated. RU values close to 1 indicate parameters best positioned to detect a change in keratoconic eyes.ResultsThe tolerance index values indicated that 36% of ocular parameters for keratoconic eyes had repeatability limits which were wider than normative limits (worse), but 28% of the ocular parameters were narrower than normative limits (better). Considering only those parameters with a RU greater than 0.95, a small number of parameters were within this range, such as corneal curvature and asphericity indices.ConclusionsThis study demonstrates that measurement error in keratoconic eyes is significantly greater than healthy eyes. Indices implemented here provide guidance on the levels of expected precision in keratoconic eyes relative to healthy eyes to aid clinicians in distinguishing real change from noise. Importantly maximal keratometry (Kmax), central corneal thickness (CCT) and thinnest corneal thickness (TCT) were highlighted as problematic indices for the follow-up of keratoconus in terms of repeatability.

Objective Assessment of Activity Limitation in Glaucoma with Smartphone Virtual Reality Goggles: A Pilot Study

Purpose To evaluate the use of smartphone-based virtual reality to objectively assess activity limitation in glaucoma. Methods Cross-sectional study of 93 patients (54 mild, 22 moderate, 17 severe glaucoma). Sociodemographics, visual parameters, Glaucoma Activity Limitation-9 and Visual Function Questionnaire – Utility Index (VFQ-UI) were collected. Mean age was 67.4 ± 13.2 years; 52.7% were male; 65.6% were driving. A smartphone placed inside virtual reality goggles was used to administer the Virtual Reality Glaucoma Visual Function Test (VR-GVFT) to participants, consisting of three parts: stationary, moving ball, driving. Rasch analysis and classical validity tests were conducted to assess performance of VR-GVFT. Results Twenty-four of 28 stationary test items showed acceptable fit to the Rasch model (person separation 3.02, targeting 0). Eleven of 12 moving ball test items showed acceptable fit (person separation 3.05, targeting 0). No driving test items showed acceptable fit. Stationary test person scores showed good criterion validity, differentiating between glaucoma severity groups (P = 0.014); modest convergence validity, with mild to moderate correlation with VFQ-UI, better eye (BE) mean deviation, BE pattern deviation, BE central scotoma, worse eye (WE) visual acuity, and contrast sensitivity (CS) in both eyes (R = 0.243–0.381); and suboptimal divergent validity. Multivariate analysis showed that lower WE CS (P = 0.044) and greater age (P = 0.009) were associated with worse stationary test person scores. Conclusions Smartphone-based virtual reality may be a portable objective simulation test of activity limitation related to glaucomatous visual loss. Translational Relevance The use of simulated virtual environments could help better understand the activity limitations that affect patients with glaucoma.

Precision of a new ocular biometer in eyes with cataract using swept source optical coherence tomography combined with Placido-disk corneal topography

The present study was to assess the precision (repeatability and reproducibility) of a new optical biometer (OA-2000, Tomey, Japan) based on swept-source optical coherence tomography (SS-OCT) and Placido disk topography in eyes with cataracts. Seventy-eight eyes from seventy-eight patients with cataracts were evaluated. Axial length (AL), anterior chamber depth (ACD), keratometry (K) over a 2.5u2009mm and 3.0u2009mm diameter, lens thickness (LT), central corneal thickness (CCT) and white-to-white (WTW) distance were measured by 2 skilled operators. OA-2000 measurements were highly repeatable and reproducible for all parameters (intraclass correlation, 0.925 to 1.000). OA-2000 derived K-values with a diameter of 3.0mm showed narrower 95% limits of agreement (LoA) (SRK/T: −0.18 to 0.16D; Holladay 1: −0.20 to 0.19D; Hoffer Q: −0.22 to 0.20D) than those with a diameter of 2.5u2009mm for IOL power calculations (SRK/T: −0.20 to 0.20D; Holladay 1: −0.23 to 0.23D; Hoffer Q: −0.25 to 0.25D). The precision (repeatability and reproducibility) of the OA-2000 was excellent for all parameters. The 3.0mm diameter K-readings appear to be the most reliable choice for calculation of IOL power with the OA-2000. In addition, the average values determined from each operator’s 3 consecutive readings were more reproducible.

Vision in high-level football officials

Officiating in football depends, at least to some extent, upon adequate visual function. However, there is no vision standard for football officiating and the nature of the relationship between officiating performance and level of vision is unknown. As a first step in characterising this relationship, we report on the clinically-measured vision and on the perceived level of vision in elite-level, Portuguese football officials. Seventy-one referees (R) and assistant referees (AR) participated in the study, representing 92% of the total population of elite level football officials in Portugal in the 2013/2014 season. Nine of the 22 Rs (40.9%) and ten of the 49 ARs (20.4%) were international-level. Information about visual history was also gathered. Perceived vision was assessed using the preference-values-assigned-to-global-visual-status (PVVS) and the Quality-of-Vision (QoV) questionnaire. Standard clinical vision measures (including visual acuity, contrast sensitivity and stereopsis) were gathered in a subset (n = 44, 62%) of the participants. Data were analysed according to the type (R/AR) and level (international/national) of official, and Bonferroni corrections were applied to reduce the risk of type I errors. Adopting criterion for statistical significance of p<0.01, PVVS scores did not differ between R and AR (p = 0.88), or between national- and international-level officials (p = 0.66). Similarly, QoV scores did not differ between R and AR in frequency (p = 0.50), severity (p = 0.71) or bothersomeness (p = 0.81) of symptoms, or between international-level vs national-level officials for frequency (p = 0.03) or bothersomeness (p = 0.07) of symptoms. However, international-level officials reported less severe symptoms than their national-level counterparts (p<0.01). Overall, 18.3% of officials had either never had an eye examination or if they had, it was more than 3 years previously. Regarding refractive correction, 4.2% had undergone refractive surgery and 23.9% wear contact lenses when officiating. Clinical vision measures in the football officials were similar to published normative values for young, adult populations and similar between R and AR. Clinically-measured vision did not differ according to officiating level. Visual acuity measured with and without a pinhole disc indicated that around one quarter of participants may be capable of better vision when officiating, as evidenced by better acuity (≥1 line of letters) using the pinhole. Amongst the clinical visual tests we used, we did not find evidence for above-average performance in elite-level football officials. Although the impact of uncorrected mild to moderate refractive error upon officiating performance is unknown, with a greater uptake of eye examinations, visual acuity may be improved in around a quarter of officials.