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Abstract Background All aspects of the heath care sector are being asked to account for their performance. This poses unique challenges for local public health units with their traditional focus on population health and their emphasis on disease prevention, health promotion and protection. Reliance on measures of health status provides an imprecise and partial picture of the performance of a health unit. In 2004 the provincial Institute for Clinical Evaluative Sciences based in Ontario, Canada introduced a public-health specific balanced scorecard framework. We present the conceptual deliberations and decisions undertaken by a health unit while adopting the framework. Discussion Posing, pondering and answering key questions assisted in applying the framework and developing indicators. Questions such as: Who should be involved in developing performance indicators? What level of performance should be measured? Who is the primary intended audience? Where and how do we begin? What types of indicators should populate the health status and determinants quadrant? What types of indicators should populate the resources and services quadrant? What type of indicators should populate the community engagement quadrant? What types of indicators should populate the integration and responsiveness quadrants? Should we try to link the quadrants? What comparators do we use? How do we move from a baseline report card to a continuous quality improvement management tool? Summary An inclusive, participatory process was chosen for defining and creating indicators to populate the four quadrants. Examples of indicators that populate the four quadrants of the scorecard are presented and key decisions are highlighted that facilitated the process.

Objective: This study aimed to evaluate the long-term graft survivability of locally prestripped versus imported prestripped Descemet membrane endothelial keratoplasty (DMEK) grafts in Edmonton., Design: Prospective cohort study of patients who underwent DMEK surgery between January 1, 2020, and December 31, 2020., Participants: All patients receiving a DMEK transplant during the study period in Edmonton., Methods: Two local technicians were trained to prestrip DMEK grafts in Edmonton. When available, local tissue was prestripped for DMEK surgery; otherwise, prestripped DMEK grafts were imported from an accredited American eye bank. Patient characteristics and DMEK graft characteristics and DMEK survivability were evaluated and compared between the 2 groups., Results: Thirty-two locally prestripped DMEK grafts and 35 imported prestripped DMEK grafts were used during the study period. Donor cornea characteristics and patient characteristics were similar between the 2 groups. Best-corrected visual acuity improved up to 6 months postoperatively and was 0.2 logMAR in the locally prestripped DMEK group and 0.2 logMAR in the imported DMEK group (p = 0.56). Rebubble rates were 25% in the locally prestripped DMEK group and 19% in the imported DMEK group (p = 0.43). There was 1 primary graft failure in each group (p = 0.93). Endothelial cell density decreased by 37% in the locally prestripped DMEK group and by 33% in the imported DMEK group 2 years after transplantation., Conclusions: The long-term survivability of locally prepared DMEK grafts is comparable with that of DMEK grafts imported from American eye banks., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to show the cost-effective benefits of creating a sustainable local program where Descemet membrane endothelial keratoplasty (DMEK) grafts were prepared locally instead of imported from American eye banks., Design: Retrospective observational study., Methods: In 2018, 2 local technicians were trained to prestrip DMEK grafts in Edmonton up to 2 days before surgery when local donor tissue was available. When no local tissue was available, prestripped DMEK grafts were imported from U.S. eye banks. The total cost of locally prepared and imported DMEK grafts over 27 months was compared with the cost that otherwise would have been accrued if all DMEK grafts had been imported., Results: Over 27 months, 82 DMEK grafts (55.3%) were prepared locally and 63 DMEK grafts (44.7%) were imported. The total cost of preparing 82 grafts locally was $9349.19. The total cost of importing 63 prestripped DMEK grafts was $282 431.52. The combined total cost of locally prepared and imported DMEK grafts was $291 780.71. The total cost that otherwise would have been incurred if every graft was imported was $632 108.64. This difference in costs was $340 327.93 over 27 months., Conclusions: Establishing a sustainable program to make high-quality DMEK grafts with local donor corneas is a cost-effective alternative to importing prestripped DMEK grafts in Edmonton., (Copyright © 2022 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the steps, hurdles, and recommendations for implementation of the immediately sequential bilateral cataract surgery (ISBCS) evidence-based protocol at a high-volume Canadian tertiary care centre., Design: Quality-improvement study., Participants: A total of 406 patients who underwent ISBCS from July 2020 to December 2020. Patients were selected based on specific inclusion and exclusion criteria including psychosocial factors, refractive error and consent. This initiative impacted staff at all levels involved with cataract surgery., Methods: The Model of Improvement framework was used and involved numerous discussions with multidisciplinary teams of ophthalmologists, nursing and support staff, management, pharmacists, and medical device reprocessing teams. This initiative was created and refined via a thorough review of the literature and current best practices. It was implemented in July 2020 after a nursing "huddle." Any adverse outcomes and overall impact were collected from various levels of staff involved., Results: Each eye was treated as a separate surgery with a double time-out per bilateral case. Additional measures were taken to ensure different lot numbers for medications, equipment, and materials. This practice increased surgical volume by approximately 25% and reduced the number of patient visits by 50%, reducing potential COVID-19 exposure., Conclusions: The resulting protocol from our study may be useful to other centres wishing to integrate ISBCS as one example of successful implementation. Of the 406 cases of ISBCS performed, we report zero cases of toxic anterior segment syndrome or endophthalmitis. In times of decreased elective surgeries, ISBCS is a safe and effective option to supplement surgical volume and provide significant patient benefits., (Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the long-term clinical outcomes of conjunctival limbal autograft (CLAU) in patients with unilateral total limbal stem cell deficiency (LSCD)., Methods: In this retrospective interventional case series, the medical charts of patients with unilateral total LSCD were reviewed. Patients who underwent CLAU and no other allograft ocular stem cell transplantation with a minimum follow-up of 1 year were included. Main outcome measures were ocular surface stability, best-corrected visual acuity (BCVA), and postoperative complications., Results: 27 eyes fulfilled the inclusion criteria with a mean follow-up period of 49.8 ± 36.6 months (4.15 years; range 12-186.72 months; 1-15.56 years). Ocular surface stability was achieved in 77.8% (n = 21) of eyes at last follow-up, while 22.2% (n = 6) developed partial surface failure. Optical penetrating or deep lamellar anterior keratoplasty was performed in 44.45% (n = 12). BCVA improved from 1.42 ± 0.95 mean LogMAR (equivalent to 20/400) preoperatively to 0.53 ± 0.47 mean LogMAR (equivalent to 20/70) at last follow-up (p < 0.001). BCVA ≥20/40 was achieved in 44.45% (n = 12) at last follow-up. Microbial keratitis occurred in 14.81% (n = 4). Ocular hypertension secondary to corticosteroid use developed in 25.9% (7/27) eyes. There were no other complications in the donor or recipient eyes., Conclusions: CLAU can provide long-term ocular surface stability and successful visual outcomes in patients with unilateral LSCD., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To study indications for penetrating keratoplasty (PK) at a single site. The trends in the causative organisms for infectious keratitis requiring surgery were also evaluated., Design: Retrospective observational study., Participants: A total of 1181 eyes of 935 patients undergoing PK between January 2000 and December 2015 in Northern Alberta, Canada., Methods: Indications for PK were evaluated over the 16-year study period, and the trends in these indications were compared over 5-year intervals. The microbiology of infectious keratitis cases requiring surgery was similarly evaluated., Results: The most common indications for PK from 2000 to 2015 were keratoconus (23%), re-graft (22%), and corneal scar (12%). There was a decline in the percent of total surgeries done for Fuchs' dystrophy (p = 1.1 × 10 -3 ) and pseudophakic bullous keratopathy (p = 5.6 × 10 -5 ), whereas a corresponding increase in keratoconus (p = 3.2 × 10 -5 ), trauma (p = 2.1 × 10 -3 ), and infectious keratitis cases (p = 0.010) was observed. The most common causes for infectious keratitis cases were viral (45%), bacterial (18%), parasitic (11%), and fungal (9%). There was a significant increase in the percent of infectious keratitis cases due to a viral etiology from 2005 to 2010 (p = 6.4 × 10 -3 )., Conclusions: The indications for PK are comparable with other centres in North America. Nearly half of all infectious keratitis cases requiring surgery are viral. The increase in viral cases requiring surgery may reflect improved diagnostics or recurrent cases., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

The cornea is unique because of its complete avascularity. Corneal neovascularization (CNV) can result from a variety of etiologies including contact lens wear; corneal infections; and ocular surface diseases due to inflammation, chemical injury, and limbal stem cell deficiency. Management is focused primarily on the etiology and pathophysiology causing the CNV and involves medical and surgical options. Because inflammation is a key factor in the pathophysiology of CNV, corticosteroids and other anti-inflammatory medications remain the mainstay of treatment. Anti-VEGF therapies are gaining popularity to prevent CNV in a number of etiologies. Surgical options including vessel occlusion and ocular surface reconstruction are other options depending on etiology and response to medical therapy. Future therapies should provide more effective treatment options for the management of CNV., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To investigate efficacy and safety of phaco-trabectome (PT) versus phaco-iStent (Pi) for intraocular pressure (IOP) control in open-angle glaucoma (OAG)., Design: Retrospective comparative case series., Participants: A total of 70 eyes of 55 patients with OAG underwent either PT surgery by a single surgeon or Pi (insertion of 2 stents) by another surgeon in Canada between January 2010 and December 2012., Methods: The medical records of consecutive adult patients who underwent either PT or Pi surgery were reviewed. All patients who satisfied both the inclusion and exclusion criteria were included in the outcomes analyses. IOP reduction, reduction in glaucoma medication, safety profile, and best-corrected visual acuity were evaluated., Results: Thirty-six eyes of 30 patients had PT and 34 eyes of 25 patients had Pi. Baseline IOP was higher in the PT group (20.92 ± 5.07 mm Hg) than in the Pi group (17.47 ± 4.87 mm Hg; p = 0.026). At 12 months there was no significant difference between groups in relative reduction of mean IOP (PT -5.09 ± 5.73, 24% relative reduction vs. Pi -3.84 ± 3.80, 22% relative reduction; p = 0.331) or glaucoma medication use (PT -0.49 ± 1.17 vs. Pi -0.26 ± 0.73; p = 0.168) from baseline. However, Pi had significantly fewer individual complications (PT 20 vs. Pi 5; p < 0.0001) throughout the postoperative period., Conclusion: At 12 months of follow-up, both techniques significantly lowered IOP, but fewer complications were observed in the Pi group., (Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Age related macular degeneration (AMD) is one of the leading causes of blindness in Western society. A hallmark of early stage AMD are drusen, extracellular deposits that accumulate in the outer retina. Advanced glycation endproducts (AGE) accumulate with aging and are linked to several age-related diseases such as Alzheimer's disease, osteoarthritis, atherosclerosis and AMD. AGE deposits are found in drusen and in Bruch's membrane of the eye and several studies have suggested its role in promoting oxidative stress, apoptosis and lipofuscin accumulation. Recently, complement activation and chronic inflammation have been implicated in the pathogenesis of AMD. While AGEs have been shown to promote inflammation in other diseases, whether it plays a similar role in AMD is not known. This study investigates the effects of AGE stimulation on pro- and anti-inflammatory pathways in primary culture of human retinal pigment epithelial cells (RPE). Differential gene expression studies revealed a total of 41 up- and 18 down-regulated RPE genes in response to AGE stimulation. These genes fell into three categories as assessed by gene set enrichment analysis (GSEA). The main categories were inflammation (interferon-induced, immune response) and proteasome degradation, followed by caspase signaling. Using suspension array technology, protein levels of secreted cytokines and growth factors were also examined. Anti-inflammatory cytokines including IL10, IL1ra and IL9 were all overexpressed. Pro-inflammatory cytokines including IL4, IL15 and IFN-γ were overexpressed, while other pro-inflammatory cytokines including IL8, MCP1, IP10 were underexpressed after AGE stimulation, suggesting a para-inflammation state of the RPE under these conditions. Levels of mRNA of chemokine, CXCL11, and viperin, RSAD2, were up-regulated and may play a role in driving the inflammatory response via the NF-kB and JAK-STAT pathways. CXCL11 was strongly immunoreactive and associated with drusen in the AMD eye. The pathways and novel genes identified here highlight inflammation as a key response to AGE stimulation in primary culture of human RPE, and identify chemokine CXCL11 as putative novel agent associated with the pathogenesis of AMD., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: To assess patient preference for diabetic retinopathy (DR) screening with teleophthalmology or face-to-face ophthalmologist evaluation in Nairobi, Kenya., Materials and Methods: Fifty seven diabetic patients from a one-stop multidisciplinary diabetic clinic (consisting of a diabetologist, nurse educator, foot specialist, nutritionist, ophthalmologist, and neurologist) in Nairobi, Kenya were included if they had undergone both a teleophthalmology (stereoscopic digital retinal photographs graded by an ophthalmologist remotely) and a traditional clinical screening exam (face to face examination). A structured questionnaire with a 5-point Likert scale was developed in both English and Swahili. The questionnaire was administered over the telephone. Ten questions were used to compare patient experience and preferences between teleophthalmology and a traditional clinical examination for DR. A mean score >3.25 on the Likert scale was considered favourable., Results: Successfully telephone contact was possible for 26 (58% male, 42% females) of the 57 patients. The mean ages of the male and female patients were 52.4 and 46.5 years respectively. Patients were satisfied with their teleophthalmology examination (mean 4.15 ± 0.97). Patients preferred the teleophthalmology option for future screenings (mean 3.42 ± 1.52). This preference was driven primarily by convenience, reduced examination time, and being able to visualize their own retina., Conclusion: In this study, diabetic patients preferred a teleophthalmology based screening over a traditional ophthalmologist-based screening. The use of teleophthalmology in Africa warrants further study and has the potential to become the screening model of choice. Cost effectiveness in comparison to an ophthalmologist-based screening also requires evaluation.

Since its initial discovery as Ca(2+)/calmodulin (CaM)-dependent serine/threonine protein phosphatase, calcineurin (CaN) has been extensively studied in many mammalian tissues. CaN has been shown to be involved in various biological and Ca(2+)-dependent signal transduction pathways. Over the last decade, our laboratory has been interested and has carried out numerous experiments on this specific protein phosphatase. While, a lot of research has been performed studying CaN's involvement in ischemia, the immune system, and various mammalian tissues, not much is known about the potential role of CaN in various eye diseases. This review focuses on the studies that have been carried out in our laboratory on CaN, and specifically CaN's involvement in the eye. We demonstrated that CaN is localized in various eye tissues (cornea, iris, ciliary body, vitreous body, retina, choroid, sclera, and optic nerve) and that both its protein expression and activity were observed in high amounts in the retina, optic nerve and cornea. Recently, we have cloned and characterized the CaN A and B subunits in the bovine retina. These initial findings suggest that CaN may play a potential role in visual transduction and various ocular diseases, including cancer.

Background: All aspects of the heath care sector are being asked to account for their performance. This poses unique challenges for local public health units with their traditional focus on population health and their emphasis on disease prevention, health promotion and protection. Reliance on measures of health status provides an imprecise and partial picture of the performance of a health unit. In 2004 the provincial Institute for Clinical Evaluative Sciences based in Ontario, Canada introduced a public-health specific balanced scorecard framework. We present the conceptual deliberations and decisions undertaken by a health unit while adopting the framework., Discussion: Posing, pondering and answering key questions assisted in applying the framework and developing indicators. Questions such as: Who should be involved in developing performance indicators? What level of performance should be measured? Who is the primary intended audience? Where and how do we begin? What types of indicators should populate the health status and determinants quadrant? What types of indicators should populate the resources and services quadrant? What type of indicators should populate the community engagement quadrant? What types of indicators should populate the integration and responsiveness quadrants? Should we try to link the quadrants? What comparators do we use? How do we move from a baseline report card to a continuous quality improvement management tool?, Summary: An inclusive, participatory process was chosen for defining and creating indicators to populate the four quadrants. Examples of indicators that populate the four quadrants of the scorecard are presented and key decisions are highlighted that facilitated the process.