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Raj Bhayani,1 Andrew Walkden1,2 1Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK; 2School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UKCorrespondence: Andrew Walkden, Email walkdenandrew@gmail.comAbstract: Corneal transplantation, when used in the correct setting, can significantly improve visual acuity and therefore quality of life. One of the barriers to good vision following keratoplasty is residual post operative surgical astigmatism. Following a thorough literature search, we present the different options available to readers, with regards to how post-operative astigmatism can be approached and managed in order to improve vision. We present available data from the literature, which in some areas are scarce, with a view to collating all of this information in one place, allowing comparison between different modalities of treatment.Keywords: penetrating keratoplasty, astigmatism, post graft astigmatism, corneal transplant astigmatism

Joanna Przybek-Skrzypecka,1,2 Andrew Walkden,3,4 Arun Brahma,3 Jaya Chidambaram,5 Fiona M Carley3,6 1Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland; 2SPKSO Ophthalmic University Hospital, Warsaw, Poland; 3Cornea Department, Manchester Royal Eye Hospital, Manchester University NHS Foundation, Manchester, UK; 4School of Biological Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; 5Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; 6School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UKCorrespondence: Joanna Przybek-Skrzypecka, Department of Ophthalmology, Medical University of Warsaw, Marszałkowska 24/26, Warsaw, 00-576, Poland, Tel +48 22 511 62 37, Email przybek.joanna@gmail.com; joanna.przybek-skrzypecka@wum.edu.plBackground: To assess the difference in course and final visual outcome of Acanthamoeba keratitis (AK) patients based on the first healthcare provider (HCP) seen.Methods: Retrospective observational cohort study of AK patients admitted to the Manchester Royal Eye Hospital between 2003 and 2017. HCPs were grouped (Group 1: Optometrists, Opticians; Group 2: General Practitioners (GPs); Group 3: Ophthalmologists) and the data analyzed on demographics, risk factors, clinical history, clinical features, and Acanthamoeba subspecies.Results: Forty-one patients with unilateral culture-proven AK were included. Median time to consultation with first HCP was 7 days (IQR 4– 14 days), while mean time to the correct diagnosis of AK was 15 days (IQR 7– 29 days). Patients saw an optician, optometrist or ophthalmologists significantly earlier than GPs (median 4 days, vs 15 or 5 days, respectively, p = 0.04). Bacterial keratitis was the most common initial clinical diagnosis (43%). The shortest time to making the AK diagnosis (median 11 days) and the highest rate of initiating AK treatment started at the first visit (38%) were both in the ophthalmologists’ group. No significant differences were observed in initial and final visual acuity between HCP groups (p = 0.36).Conclusion: AK patients often seek ocular help earlier from optometrists and opticians than medical doctors. Final clinical outcomes did not significantly differ based on the first HCP seen, but ophthalmologists were more likely to make the diagnosis of AK and initiate anti-amoebal therapy faster than other HCPs. Greater education and collaboration between ophthalmologists and other HCPs to increase awareness of AK are needed.Keywords: keratitis, Acanthamoeba, corneal ulcer, diagnosis, healthcare providers

Luke Michaels,1 Jay Richardson,1 Andrew Walkden,1,2 Fiona Carley1,2 1Manchester Royal Eye Hospital, Manchester, UK; 2Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UKCorrespondence: Andrew Walkden, Manchester Royal Eye Hospital, Oxford Road, Manchester, Greater Manchester, M13 9WL, UK, Tel +44 161-276-1234, Email walkdenandrew@gmail.comPurpose: The COVID-19 pandemic has led to drastic changes to the daily lives of those living in the United Kingdom. We hypothesized that the effect of the imposed lockdown on both behaviour and social interaction has the potential to influence the characteristics of microbial keratitis presenting locally to Manchester Royal Eye Hospital — a major tertiary eye centre in the UK.Methods: We conducted a retrospective case-note review of all positive corneal scrape cultures identified by our local microbiology laboratory during the year since the announcement of lockdown measures in the UK (23 March 2020 to 23 March 2021). Culture results were compared with previously collated, published “baseline” data from prior to the onset of the COVID-19 pandemic (2004– 2019). Statistical analysis was undertaken, predominantly looking at the incidence of microbial keratitis and the variety of cultured pathogens.Results: A total of 6243 corneal scrape results were reviewed. Comparison of data between the COVID-19 pandemic and subsequent lockdown did not show a significant change in the incidence of culture-positive microbial keratitis: mean annual positive samples during 2004– 2019 were 128 (35%) vs 91 (29%) during lockdown (P=0.096). No statistically significant shifts in the incidence of organism subtypes — fungi, acanthamoeba, Gram-positive bacteria, or Gram negative bacteria — were identified (P=0.196, 1, 0.366, and 0.087, respectively).Conclusion: Contrary to our hypothesis, our results suggest that the COVID-19 pandemic did not alter the incidence or characteristics of microbial keratitis presenting to Manchester Royal Eye Hospital in the year following the implementation of lockdown measures in the UK.Keywords: COVID-19, keratitis, microbiology, microbial keratitis

Yee Ling Wong,1 Siyin Liu,1,2 Andrew Walkden1,2 1Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK; 2School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UKCorrespondence: Andrew Walkden, Manchester Royal Eye Hospital, Oxford Road, Manchester, M13 9WL, UK, Email walkdenandrew@gmail.comAbstract: Disease of the cornea is the third leading cause of blindness worldwide. Corneal graft surgery is one of the most successful forms of solid organ transplantations in humans, with ever increasing developments in surgical technique. To date, approximately 4504 corneal transplants are performed in the UK each year. While full thickness transplantation was the most commonly performed keratoplasty over the last few decades, selective lamellar transplantation of the diseased layers of the cornea has been universally adopted. This comprehensive review aims to provide an updated synthesis on different types of corneal transplantations, their treatment outcomes, and the associated complications of each procedure both in adult and pediatric populations. In addition, we also present an up-to-date summary of the emerging therapeutic approaches that have the potential to reduce the demand for donor-dependent keratoplasty.Keywords: corneal transplantation, corneal blindness, keratoplasty, graft rejection, graft survival

Siyin Liu,1,2 Yee Ling Wong,1 Andrew Walkden1,2 1Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK; 2School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UKCorrespondence: Andrew Walkden, Email walkdenandrew@gmail.comAbstract: Disease of the cornea is the third leading cause of blindness worldwide. Corneal graft surgery is one of the most successful forms of solid organ transplantations in humans, with ever-increasing developments in surgical technique. To date, approximately 4504 corneal transplants are performed in the United Kingdom each year. While full thickness transplantation was the most commonly performed keratoplasty over the last few decades, selective lamellar transplantation of the diseased layers of the cornea has been universally adopted. This comprehensive review aims to provide an updated synthesis on different types of corneal transplantations, their treatment outcomes, and the associated complications of each procedure in both adult and paediatric population. In addition, we also present an up-to-date summary of the emerging therapeutic approaches that have the potential to reduce the demand for donor-dependent keratoplasty.Keywords: corneal transplantation, corneal blindness, keratoplasty, graft rejection, graft survival

Benjamin Griffin,1 Andrew Walkden,1,2 Arthur Okonkwo,1,2 Leon Au,1,2 Arun Brahma,1,2 Fiona Carley1,2 1Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; 2School of Medical Sciences, University of Manchester, Manchester, UKCorrespondence: Andrew WalkdenManchester Royal Eye Hospital, Oxford Road, M13 9WL Tel +44 7792153269Email walkdenandrew@gmail.comPurpose: To investigate the frequencies, trends, and in vitro drug susceptibilities of the causative pathogens in corneal transplant microbial infections in Manchester Royal Eye Hospital.Methods: Corneal scrape results recorded by the microbiology service between 2004 and 2015 were extracted from an established database. This microbiological data was matched with a separate database of all corneal transplant procedures performed in our centre over this time period. Patient records were examined to collect specific patient data and to confirm the diagnosis of microbial keratitis.Results: A total of 1508 grafts had been performed at our centre in this period. 72 episodes of graft microbial keratitis were identified from 66 eyes that had undergone keratoplasty procedures. Mean age was 56, and 51% of subjects were male. Ninety-three percent of microbial keratitis episodes occurred in penetrating keratoplasty procedures and 6% in deep anterior lamellar keratoplasty procedures. No endothelial grafts presented with infections throughout this time period. Of the 79 organisms identified, 73% were gram positive, 23% gram negative and 4% fungi. With regard to gram-positive organisms, vancomycin and gentamicin showed 100% and 91% susceptibility, respectively. Ofloxacin had a resistance rate of 13.7%. In terms of gram-negative organisms, gentamicin and chloramphenicol showed 100% sensitivity, with cefuroxime showing 69%. Resistance rates were less than 15% in all tested gram-negative antimicrobials.Conclusion: This paper describes the largest collection of corneal transplant infections identified within the UK. This finding may aid clinicians in predicting possible causative organisms for microbial keratitis and aid antibiotic choice.Keywords: cornea, transplant, infection, graft, microbial keratitis

Andrew Walkden1,2 1Manchester Royal Eye Hospital, Manchester University Foundation Trust, Manchester, UK; 2University of Manchester Faculty of Medical and Human Sciences, Manchester, Greater Manchester, UKCorrespondence: Andrew Walkden Email walkdenandrew@gmail.comAim: The aim of this paper is to provide a succinct literature review of the different clinical applications for AMT usage in an ophthalmic setting, ranging from commonly used applications to less mainstream approaches. The hope is that this review enables the reader to have a better understanding of the biological properties of amnion as well as the indications and scenarios in which AMT can be used, whilst presenting relevant evidence from within the literature which may be of interest. We also provide an update on the methods of preservation of amniotic membrane and the application methodologies.Methods: Literature search. A PubMed search was performed using the search terms “amniotic membrane transplant”, “amnion AND cornea”, amnion AND ophthalmology”, “amnion AND ocular surface” and “Amnion AND eye”. A full review of the literature using the PubMed database was conducted up until 01/05/20. The articles used were written in English, with all articles accessed in full. Both review articles and original articles were used for this review. All full publications related to ophthalmology were considered.Keywords: amnion, amniotic membrane transplant, amniotic membrane graft, amniotic membrane

Andrew Walkden,1,2 Leon Au,1,2 Cecilia Fenerty1,2 1Manchester Royal Eye Hospital, Manchester University Foundation Trust, Manchester, UK; 2Medical Academic Health Sciences Centre, University of Manchester, Manchester, UKCorrespondence: Andrew WalkdenManchester Royal Eye Hospital, Oxford Road, Manchester M13 9WL, UKTel +44 77 9215 3269Email walkdenandrew@gmail.comAbstract: The aim of this paper is to introduce readers to potential strategies available for teaching trabeculectomy surgery. Trainee surgical outcomes and various surgical simulation techniques are discussed, with suggestions on how to measure progress and consideration of relevant educational theories.Keywords: trabeculectomy training, ophthalmic surgical skills training, simulated surgical training, simulated trabeculectomy training, trabeculectomy surgical training

Andrew Walkden,1,2 Emma Burkitt-Wright,3,4 Leon Au1,21Manchester Royal Eye Hospital, Manchester University Foundation Trust, Manchester, UK; 2Medical Academic Health Sciences Centre, University of Manchester, UK; 3Genetic Medicine, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK; 4Genetic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UKAbstract: Brittle cornea syndrome (BCS) is a rare autosomal recessive connective tissue disorder characterised by severe corneal thinning, with the major ocular risk being spontaneous ocular perforation due to progressive stromal thinning and ectasia. It is a complex condition with limited treatment options. The purpose of this review is to highlight the difficulties associated with the condition and examine the available published evidence with regards to management.Keywords: brittle Cornea, spontaneous corneal perforation, corneal ectasia

Andrew Walkden, James F Young, Anne F Spencer, Jane AshworthManchester Royal Eye Hospital, Manchester, UKProblem: Starting ophthalmic specialty training can be daunting as new basic clinical examination and surgical skills must be acquired before meaningful assessment of patients can begin. No formal clinical induction currently exists with the aim to teach clinical and practical skills to new starters.Aim and objectives: To determine the experience and needs of ophthalmic trainees entering into specialist training. Using this information we developed and implemented a clinical skills training programme for Ophthalmology ST1s.Intervention: Using SMART objectives, PDSA cycles and Chartered Institute of Personnel Development guidance we implemented a clinical skills induction week. Pre-course skills evaluation took place in the form of a questionnaire in order to tailor the course content to the skill level of the group. Course material was made and simulation techniques devised for teaching practical skills. Qualitative data was collected via a pre- and post-course questionnaire.Outcome: All 9 participants rated the course as “extremely useful” it increased their confidence in terms of commencing clinical ophthalmology. 100% of participants felt that this course should be delivered to new ST1s. All participants reported improved confidence in managing ophthalmic emergencies and their clinical skills technique.Lessons learned: A sustainable induction programme was implemented tailored to the prior experience and skills of ST1 trainees. All participants felt it improved their confidence and clinical skills prior to commencing clinical activities. Basic clinical skills can be taught in a cost effective manner early on in postgraduate training.Keywords: ophthalmic training, starting ophthalmology, ophthalmology run-through training, ophthalmic clinical skills, ophthalmic training needs

Andrew Walkden,1,2 Leon Au1,2 1Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; 2Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK Abstract: This article aims to review the clinical management strategies available for the rare iridocorneal endothelial syndrome. The different clinical variations as well as the imaging techniques available to aid diagnosis are discussed. We then present the evidence available to help the reader to understand how the condition can be managed medically and also the important surgical aspects of treatment. This involves raised intraocular pressure management in addition to the visual management options of partial or full thickness keratoplasty. We hope that this review provides an exhaustive but also succinct review of the literature available on what is a rare and difficult condition to treat. Keywords: iridocorneal endothelial syndrome, endothelial syndrome, Cogan-Reese syndrome, Chandler syndrome, progressive iris atrophy

This essay details the author's personal process of being diagnosed with endometriosis, including her experience of medical gaslighting and societal attitudes toward "period pain." Many people who experience excessive menstrual pain report dismissive attitudes and/or trivialization of their symptoms, from both the public and health professionals. The author recalls conversations from throughout her diagnostic journey, which evidence the ingrained beliefs and attitudes of gendered observations of pain. Ultimately, the author contends that the "burden of proof" is with the patient, being forced to continually fight for their right to be heard in an archaic medical system. The people experiencing this condition are experts-by-experience, who are continually providing knowledge about endometriosis, and self-advocating to rewrite the societal narratives concerning menstrual pain. The goal of this essay is not to blame or cause discomfort, but rather to raise awareness and encourage everyone to talk more openly about menstrual related issues. The following prose is written as a first-person account of my experience with this condition, drawing on appropriate support from academic literature. [ABSTRACT FROM AUTHOR]

Objectives: The primary objective is to compare the imaging and surgical findings in a cohort of patients with suspected penile fracture (PF). Methods: Retrospective cohort study of all patients with suspected PF over an 11-year period at a tertiary referral andrology centre. All dedicated presurgical imaging with ultrasound (US) and MRI was analysed and correlated with intraoperative findings; alternative diagnoses were recorded. Results: One hundred and ninety-three patients were included. One hundred and four (54%) had alternative diagnoses to PF including dorsal vein rupture and haematoma. Ninety-nine (51%) underwent surgical exploration of which 89 (46%) had PF. US correctly confirmed the presence and marked the site of fracture in 92% of cases. MRI was primarily used as a problem-solving tool (13 cases) and demonstrated a more extensive injury than US (12 cases). The reported size of tunical defect on imaging was a median of 7 mm (IQR 4-10) significantly smaller than on exploration (median 20 mm, IQR 10-30; P < .0001). Conclusions: US has a high positive predictive value in the confirmation of PF. MRI improves the detection and characterizing the extent of injury. Imaging marking informs surgical incision but defect size is under appreciated on all imaging modalities. Advances in knowledge: Penile imaging has a high positive predictive value to not only confirm the diagnosis of PF but to stage the extent of injury and mark the skin, which impacts the surgical technique. Alternative diagnoses to fracture are common and imaging could prevent unnecessary surgical exploration. [ABSTRACT FROM AUTHOR]

Objectives: To understand the facilitators and barriers to the implementation of renal tumour biopsy (RTB) in the diagnostic pathway for renal tumours in England. Patients and Methods: Participants consisted of patients who had a renal tumour diagnosed and/or treated at one of five tertiary centres in England, healthcare professionals involved in the direct care of patients diagnosed with renal tumours, and clinical service managers and commissioners. The study employed a mixed‐methods research methodology consisting of individual interviews and an on‐line survey that explored the types of facilitators and barriers individuals perceived and experienced and the frequency in which these were reported. A public dissemination event took place following the completion of data collection; to facilitate discussion of potential solutions to implementing RTB. Results: There were 50 participant interviews (23 patients, 22 clinicians, and five health service commissioners/operations managers). The patient on‐line survey received 52 responses, and the clinician survey received 22 responses. Patients most frequently reported influences in choosing whether to undergo RTB pertained to wanting to know the diagnosis of their kidney mass (40%), the advice or information provided by healthcare professionals (40%), and not wishing to delay treatment (23%). Clinicians most frequently reported barriers to recommending RTB related to their uncertainty of diagnostic accuracy (56%), availability of appointments or hospital beds (52%), concerns of risk of bleeding (44%), risk of seeding (41%), and delays in meeting national cancer pathway targets (41%). The dissemination event was attended by 18 participants (seven patients and 11 clinicians). Suggestions to improve implementation included reducing variation and promotion of standardisation of practice by a consensus statement, increasing the evidence base (clinicians) and improved communication by developing better patient aids such as videos and diagrams (patients and clinicians). Conclusion: Implementation of RTB may be dependent on the quality of information provided, its format and perceived reliability of the information. Increased utilisation of RTB may be improved by development of a consensus statement on the role of biopsy, with patients expressing a preference for alternative information aids such as patient videos. [ABSTRACT FROM AUTHOR]

The need for early engagement in science, technology, engineering, and mathematics (STEM), and representation of role models in STEM careers is of national and international importance. The That's RAD! Science project aims to address these needs through a series of engaging picture books for younger children that feature women in STEM as role models. The goal of this research project was to use a survey tool to gain feedback from adults on their impression of the impacts and benefits on children of the That's RAD! Science books, as well as their perceptions of the benefits of STEM engagement and use of identifiable women in STEM as role models. Participants were sent a set of four That's RAD! Science books for children to engage with and the adult participant then completed an online survey. A total of 83 participants were recruited, with a 61% completion rate for the online survey. Of these, 98% identified as parents/carers. Survey data showed the That's RAD! Science books engaged children and the books are also beneficial to informal hands-on learning processes.