Category: 3. Business

Washington, DC, November 10, 2025 – Global law firm Clyde & Co today announced the appointment of Kirsten Wilkerson as a partner in its Washington, DC, office. Her arrival marks a strategic expansion of the firm’s North American Trial & Defense practice, reinforcing Clyde & Co’s position as a leading legal advisor to the insurance sector and deepening its litigation capabilities in a key market.

Kirsten Wilkerson is a seasoned litigator with 25 years of experience defending complex, high-value, and emerging tort claims. Her practice spans personal injury, mass torts, toxic exposure, and premises liability, among other areas. She also has extensive mediation experience, having negotiated structured settlements in complex cases across the country.

Eileen King Bower, Partner and Chair of Clyde & Co’s North American Board commented: “Kirsten brings a proven ability to craft and execute litigation strategies in some of the most complex and high-stakes cases. Her appointment reflects our ongoing commitment to expanding our insurance capabilities across the US and will further enhance our ability to deliver outstanding service and results for our clients.”

Kirsten Wilkerson commented: “Joining Clyde & Co offers an exciting opportunity to contribute to its highly respected Trial & Defense practice. My experience handling complex tort claims, from environmental and toxic exposure to premises liability, aligns closely with the firm’s strategic focus. I’m looking forward to working alongside talented colleagues across the firm and helping clients navigate the challenges of high-stakes litigation.”

Clyde & Co is a leading global law firm with a robust North American practice that offers clients industry-leading advisory and dispute resolution services. The firm opened its first North American office in New York in 2006. Since then, the firm has grown to 19 offices with more than 400 attorneys across the US and Canada, including more than 100 partners.

 

Introduction

More than half a billion people with distance vision impairment caused by anterior segment pathologies^1–3 live in low- and middle-income countries (LMICs).⁴ Vision impairments from cataracts and the sequelae of microbial keratitis and trauma are the fourth most common disability in Uganda, affecting 6.7% of the population.^3,5–7 This significantly reduces the ability of those affected to contribute to the country’s productivity.⁵ The situation is mainly due to the low number of ophthalmologists (fewer than two per million people), with the vast majority based in urban areas.⁶ Although task shifting, through the expansion of a trained ophthalmic clinical officer (OCO) cadre, has been established, many healthcare workers cannot access functioning diagnostic devices, such as slit lamps, which limits the potential impact of this capacity strengthening strategy.⁸

The handheld slit lamp is suitable for both clinical and community outreach use and is a portable version of the gold standard (slit lamp) for diagnosing anterior segment eye diseases.^9,10 However, it is costly, easily broken, and requires regular maintenance with access to often hard-to-find and expensive consumables. It is also perceived as challenging to operate, requiring a relatively long training period to reach competence. These factors together limit its use in resource-limited settings, especially among primary and mid-level healthcare workers, who are typically the first to see patients with anterior segment eye diseases.^8,11 Additionally, Uganda has very few (<20) working slit lamps in public hospitals, which delays the diagnosis of preventable and curable anterior segment diseases.^11,12 The Lancet commission and Vision 2020 initiative recommend developing low-cost, portable devices for LMICs that are independent of scarce and expensive consumables without compromising core function.^1,13

In response to the issues outlined above, the Arclight device has been designed and developed. It is a portable (weighs 18g), solar-powered, low-cost combination anterior segment loupe, ophthalmoscope, and otoscope.^14,15 The time to fully charge the device is 4–6 hours in the sun or 45–60 minutes via USB. Several studies have demonstrated the direct ophthalmoscope function to be equal to traditional direct ophthalmoscopes in performing the fundal “red” reflex and fundoscopy.^16–20 Additionally, it is easier to use, with a shorter learning curve for those with minimal eye care training.^16,18,21,22 These features make the Arclight potentially suitable for use by generalists and mid-level eye care workers in delivering primary eye care. In addition, the otoscope function has been evaluated in both high- and low-resource settings and has also been shown to be of equivalent function to traditional, more expensive devices.^17,23 As yet, however, evidence for the Arclight’s use in the examination of anterior segment disease has not been explored. Therefore, this study aimed to evaluate the accuracy and acceptability of the Arclight anterior segment loupe compared to the handheld slit lamp in the diagnosis of common anterior segment eye diseases seen by OCOs in Uganda.

Methods

Study Design

This was a mixed-methods cross-sectional study employing both qualitative and quantitative techniques conducted in June 2022.

Study Site

The study was carried out at the ophthalmology outpatient clinics of Mulago National Super Specialised Hospital (MNSH). MNSH is the only public hospital providing specialized ophthalmic services in central Uganda and also serves as the teaching hospital for Makerere University.

Study Population

The study recruited Ophthalmic Clinical Officers (OCOs) from three districts in the central region of Uganda: Wakiso District, Mukono District, and Kampala District, which were purposively selected. Ophthalmic Clinical Officers (OCOs) undergo a one-year diploma specialized training in clinical ophthalmology, including diagnosis and non-surgical treatment of eye diseases.

Sample Size Estimation

A total of 21 OCOs were recruited. The sample size was calculated using a desired precision of 0.05, a mean diagnosis time with the Arclight device of 93.19 seconds,¹⁶ and adjustments for the expected number of subjects during the study period, as well as a 10% non-response rate.²⁴ Participants were sampled consecutively from the list of the National Association of Ophthalmic Clinical Officers and Cataract Surgeons.

Three focus group discussions (FGDs) were planned to be conducted face-to-face, with each FGD consisting of six participants to ensure theme saturation. Participants were purposively sampled from the OCOs who took part in the quantitative phase of the study.

Study Procedures

Arclight Training Session

A one-day workshop on both the hand-held slit lamp and the Arclight device was conducted for the participants. The workshop emphasized examination techniques and diagnosis of common anterior segment eye diseases.

Selection of Patients

Two ophthalmologists with over 5 years of experience (AK and CN) recruited patients with the following diagnoses made on a table-mounted slit lamp: normal eye, chronic anterior uveitis, pterygium, corneal ulcer, corneal laceration, corneal scar, hypopyon, hyphema, trachomatous trichiasis, pupil abnormality, cataract, and papillary conjunctivitis.

Data Collection Stage

After obtaining written informed consent from both the OCOs and patients, research assistants (CN & AK) administered a questionnaire to collect data on the OCOs’ age, gender, length of practice in ophthalmology, district of practice, and experience with the Arclight device.

Each OCO was randomly assigned to use either the Arclight or a handheld slit lamp first. Then, each participant examined all 12 patients and recorded the diagnosis. To reduce the chance of recall from short-term memory, the order of patients was changed before switching to the other device and conducting the second set of examinations. Patients were also disguised with a gown, a theatre cap, and masks, leaving only their eyes visible to the participants. To minimize patient fatigue, each patient’s eye was examined a maximum of 11 participants using each device, and thus 2 groups of patients with the predetermined conditions were recruited; however, every OCO examined the same set of patients with the 2 devices. Within each group, each participant was examined by 2 devices.

Focus Group Discussions

FGDs were facilitated by a doctor trained in qualitative research data collection (AWS) and a trained note-taker (PAO). Each session lasted 80 minutes, with participants seated around a round table and the moderator among them. Before each FGD began, the moderator explained the study’s objectives to the participants.

A questionnaire based on Sekhon’s Model of Acceptability of Health Intervention²⁵ was used to collect data (S1), with all FGDs recorded and field notes taken by the PAO.25 FGDs were conducted until thematic saturation was reached. The recordings were transcribed by a skilled transcriber and reviewed by the investigators to ensure they conformed to the submissions from the FGDs.

Data Analysis

Quantitative

Descriptive statistics were summarized as frequencies, percentages, medians, and interquartile ranges. Data was visualized using bar graphs. The performance of the devices was presented as the percentage of diagnoses correctly identified and compared using McNemar’s test.

Qualitative

All audio recordings were transcribed verbatim in English and verified by two research assistants. All qualitative data were analyzed using a thematic approach in NVIVO software. De-identified data, organized in transcripts, were read multiple times by JM to identify relevant text segments and group them into codes. We also combined similar paragraphs into meaning units, which were then synthesized to create codes. These codes were further analyzed to identify themes using constructs from Sekhon’s Theoretical Framework of Acceptability.²⁵ This framework includes seven constructs, which are adapted as shown in Table 1.

Table 1 Table Showing the Adaptation of Sekhon’s Framework to Our Study

We developed a narrative of our qualitative data based on the identified themes and included quotes from the FGDs to illustrate the participants’ views. Participants did not provide feedback on our findings. We present our results following the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist.²⁶

Results

Study Participant Characteristics

In this cross-sectional study, 21 OCOs (13 females) were recruited, with a median age of 39 years. All OCOs had practiced for more than 5 years and had experience using a handheld slit lamp. Only 6 participants had previous exposure to Arclight. The details of the participant characteristics are displayed in Table 2.

Table 2 Characteristics of the Study Participants

Diagnostic Accuracy of the Arclight Loupe versus the Handheld Slit Lamp

Most conditions were accurately identified by the OCOs: Arclight (71.2%) and handheld slit lamp (72.3%). The percentages of correct diagnoses are displayed in Table 3 and Figure 1.

Table 3 Proportion of Participants Who Correctly or Wrongly Diagnosed Eye Conditions Using Arclight Device versus Handheld Slit Lamp

Figure 1 The percentage of OCOs who got the correct diagnoses using Arclight device versus hand-held slit lamp. Note: *p-value <0.05.

The median time taken to make the diagnosis was comparable between the devices: handheld slit lamp 26 seconds and Arclight 25 seconds. An almost perfect agreement between devices was observed for diagnosing Endophthalmitis/hypopyon (Cohen’s Kappa: 1.00 (1.000—1.000)) and Trachomatous trichiasis (Cohen’s Kappa: 0.8966 (0.700—1.000)), while substantial agreement was noted for diagnosing corneal ulcer (Cohen’s Kappa: 0.7667 (0.461—1.000)) (Table 4). More OCOs misdiagnosed corneal scars using Arclight compared to the slit lamp (13 [61.9%], 95% CI [38.3—80.9] vs 6 [28.6%], 95% CI [12.5—52.9], p-value 0.019). No agreement was observed between devices in diagnosing cataract (Cohen’s Kappa: 0.000 [−Infinity—1.000]) or Pterygium (Cohen’s Kappa: 0.000 [−Infinity—1.000]).

Table 4 Agreement Between the Arclight Device and Slit Lamp per Anterior Segment Eye Condition

Acceptability of Using the Arclight Device in the Diagnosis of Common Anterior Segment Eye Disease

We used Sekhon’s Theoretical Framework of Acceptability to assess findings from the FGDs on the acceptability of using Arclight. In summary, the use of the Arclight device in diagnosing common anterior segment eye diseases was acceptable to the OCOs.

Affective Attitude

User Friendliness

Participants used the Arclight device with ease and made the diagnosis in a shorter time. The quotes illustrate this:

My experience with Arclight was that it was easy for me to come up with the diagnosis within a short time. You get the gadget (Arclight), you focus quickly on the patient’s eye, and you have the right diagnosis. (FGD 1)

It Requires Minimal Training

Generally, almost all participants stated that they required minimal training to use the device efficiently in their clinical practice. The techniques to arrive at a correct diagnosis were easy to grasp in a short time. One participant reiterated

In a short time, I learnt and acquired skills on how to use the Arclight very well on the anterior segment examination and fundoscopy. (FGD 3)

Portability

One participant shared, “I can even move with it in my small bag and do my community work.”

Most of the OCOs said that Arclight was easy to carry from one place to another. They attributed this to its smaller size compared to the slit lamp, which they used for diagnosing anterior eye segment diseases.

The Arclight is light (in terms of weight) compared to the Slight lamp, and you can move with it. Now we can even do home-to-home visits, looking at people’s eyes. (FGD 1)

The Arclight Is an Affordable and Easy-to-Maintain Device

Cost also emerged as another factor that the OCOs preferred over the slit lamp. The participants felt that it was more realistic to purchase an Arclight for their practice.

Of course, the cost attached will always affect my decision to use it because when you compare the two, 50,000 Uganda shillings (for the Arclight) is easily obtained than 35 million Uganda shillings, and they almost use the same time to arrive at the diagnosis, apart from a few cases. You will choose the Arclight. (FGD 1)

The Arclight’s capacity to be recharged using solar power was viewed as a significant innovation that would enable participants to use it in hard-to-reach areas with limited access to electricity.

since it is solar charged, I can use it anywhere, even in the villages, and I wouldn’t bother about the availability of electricity in the area where I am. (FGD 3)

Self-Efficacy

Able to Use It to Diagnose Anterior Segment Conditions

The participants regarded the Arclight as a valuable device that would aid in diagnosing anterior segment diseases. As two participants observed:

I found the Arclight device easy to manoeuvre and use to make diagnoses for anterior segment conditions. I did not have to make a lot of adjustments like when I use the slit lamp (FGD 3)

Arclight can be used in mass screening exercises

The participants believed they could use the Arclight device in their clinics and medical outreach efforts to evaluate a large number of patients quickly. Two participants mentioned this.

I would prefer the Arclight device (to the portable slit lamp) because it is simpler to use, and you can handle many patients within the shortest time. The Arclight device would also be better (than the slit lamp) If I go for an outreach or camp (FGD 1)

It Can Be Used to Examine a Wide Range of Patients

The ability of participants to use the Arclight device with different patient groups emerged as a key issue during the focus group discussions (FGDs). The majority of the OCOs who had undergone training before using the Arclight felt that they could use the device with children who may not be cooperative or have limited ability to follow instructions.

It can be used to examine both the cooperative and uncooperative patient. The portable slit lamp may not provide accurate results if the patient is uncooperative. The Arclight device is a good device to use to examine children who easily get tired, and they are moving up and about. (FGD 2)

However, some participants experienced challenges in adjusting to using the Arclight device for diagnosing common anterior segment eye diseases.

My challenge was to adjust because we are used to these (instruments), which have a bigger working surface area. So, for me to focus on that small area in the beginning was hard for me. (FGD 2)

Burden

High Time Efficiency

For most participants, the average time to reach a diagnosis was shorter with the Arclight than with the slit lamp. The participants noted:

The duration (to reach a diagnosis using the Arclight) was quite short. It is less than one minute, and you are already there. (FGD 1)

Perceived Effectiveness and Opportunity Cost

Our analysis found themes that overlapped in these constructs and hence are presented jointly:

High Preference for the Arclight

Participants in our study stated that they were able to use the Arclight to identify the common anterior segment conditions. In addition, some of the OCOs felt that the Arclight provided good magnification, enabling them to make a diagnosis in a very short time.

I would prefer to use the Arclight to the slit lamp. (With the Arclight device), I was able to examine the depth and everything in the anterior segment. (FGD 3)

In comparison with other alternative devices used in eye care in Uganda, the participants in the FGDs felt that Arclight would provide them with the opportunity to diagnose their patients. This is despite their acknowledgment that the slit lamp remains the gold standard.

For the case of our settings, the fact that we lack infrastructure and equipment, I guess the Arclight device is more flexible to use compared to other tools. But as the gold standard, the slit lamp stands out better because it comes with other accessories and magnifications. When it comes to eye care (in our settings), which runs largely on outreaches, I think Arclight makes a difference. (FGD 2)

However, participants also noted potential limitations with the effectiveness of Arclight:

Perceived Technical Limitations of the Arclight

Arclight Increases Exposure to Pathogenic Aerosols

To obtain accurate results, the participants had to stand close to the patients, which made them (OCOs) uncomfortable The OCOs felt that this increased their exposure to possible pathogens (especially aerosols from infected patients) for their patients. One participant reiterated:

In cases where I suspect infections or in cases where I suspect flu because of the proximity of the patient to me, I might be discouraged from using the Arclight device for fear of acquiring an infection from the patient. (FGD 1)

It Cannot Make a Slit

For some conditions, the participants noted that the Arclight device might not be the most suitable device for providing sufficient depth for an extensive examination of the anterior segments of the eye. One participant noted:

There are scenarios where I think I would not use the Arclight device to examine a patient. For example, if I want to locate a specific pathology at a certain layer of the cornea, I might not use the device. This is because the Arclight device does not provide the necessary slit to enable localization of the corneal layer where the pathology is located. So, I would prefer the Slit lamp. (FGD 1)

It Is Monocular

The participants regarded the fact that Arclight was monocular as a limitation of its use in clinical practice.

The Arclight device is a monocular equipment as you use one eye to examine but with the slit lamp, you can use two eyes. There is an added advantage of depth perception (using the slit lamp) where you are going to see things very well using the two eyes. (FGD-1)

Intervention Coherence

Comprehensible Description of the Technique of Use

Participants in the FGDs demonstrated excellent comprehension of the process of using Arclight to perform anterior segment eye examinations. Two participants noted:

You establish rapport with the patient. Explain the purpose of the examination, you switch on the light, of course you go structure by structure, beginning from outside, eye lashes, eyebrows, lids, eye lashes, then like that you go to the cornea, conjunctiva then you can go to look at the anterior chamber so basically that is what it entails from outside to inwards. (FGD 2)

Ethicality

Willingness to Use the Arclight in the Future

Participants stated that based on their experiences using the Arclight, they would implement it in clinical practice for the diagnosis of anterior segment eye conditions. They hoped to use this in conjunction with the slit lamps for their practice.

I would use this device in practice always because it is easy to manage, use and carry. I do not have any reservations (FGD3)

I have access to the slit lamp already. I have been provided with an Arclight and I would definitely be using it in my practice (FGD2)

Discussion

This mixed-methods study shows that Ugandan ophthalmic clinical officers can diagnose common anterior-segment diseases with the low-cost, solar-powered Arclight loupe as accurately and quickly as with a portable slit-lamp. Across 231 examinations, the overall proportion of correct diagnoses differed by only 1.1 percentage points (71.2% vs 72.3%), and median examination times were essentially the same with the majority reporting a short learning curve. The findings therefore position the Arclight as a credible alternative to handheld slit-lamps where these are scarce, expensive, or difficult to maintain.

Our results build on previous research demonstrating the Arclight’s usefulness for posterior segment assessment and red reflex screening.^{16,18–21,27} Those studies involved medical students and general health workers. In contrast, the current trial included experienced mid-level eye-care providers and compared performance against a more advanced and costly gold standard for anterior segment examination—a handheld slit lamp—rather than an equivalent “loupe” device. The high agreement levels for inflammatory disease, trauma, trichiasis, and pseudophakia indicate that the loupe’s monocular, broad-beam optics are effective for most pathologies seen in primary eye care. The only significant clinical limitation observed was a case of corneal scarring, where examiners using the Arclight were less likely to identify it correctly. This reflects OCOs’ concerns about the absence of a slit beam and binocular depth perception.

Acceptability data help explain why diagnostic performance was maintained after only a single day of training. Participants valued the loupe’s light weight, pocket size, solar recharging, and negligible running costs—attributes that directly align with the Technology Acceptance Model’s constructs of perceived usefulness and ease of use.²⁸ Cost is especially important: purchasing one portable slit lamp costs roughly the same as 600 Arclight devices, a difference that could significantly expand access to anterior-segment screening in district hospitals and outreach programs.⁸ Additionally, users recognized the potential for quick, high-volume assessments during community eye-health camps and appreciated the practical benefit of examining children and uncooperative adults without needing chin rests or access to often hard-to-reach mains electricity.

Nevertheless, three technical limitations were identified. First, the absence of a slit beam limits the ability to locate stromal lesions and measure anterior-chamber depth, functions still best performed with a slit lamp when available. Second, monocular viewing reduces judgment of depth, which may partly explain the lower accuracy for corneal scarring. Third, clinicians need to stand very close to the patient, raising concerns about aerosol transmission of respiratory pathogens. These limitations suggest that the Arclight loupe is best used as a supplementary tool rather than a replacement: it can address a gap in diagnostic resources in health clinics and outreach settings, while slit lamps remain the preferred choice for examinations in district and tertiary hospitals, if available.

Several strengths of this study increase our confidence in the conclusions: the patient sample represents a realistic case mix, the device use order was randomized, patients were masked, and the order of cases was varied between rounds of examination. Additionally, triangulating quantitative accuracy with qualitative acceptability was employed. Limitations include the modest sample size of OCOs from districts near Kampala, the brief familiarization period with the Arclight compared to many years of slit-lamp experience, and the cross-sectional design, which cannot track changes in proficiency, device durability, or infection control practices over time. Future studies should (i) follow users longitudinally to observe learning curves and sustained acceptability; (ii) assess diagnostic accuracy for subtler conditions such as early keratoconus or Fuchs endothelial dystrophy; (iii) evaluate cost-effectiveness and effects on referral patterns; and (iv) test simple infection-control measures, such as disposable breath shields, to reduce perceived aerosol risk.

In summary, when used by trained OCOs, the Arclight loupe provides diagnostic accuracy and speed similar to a portable slit lamp, while offering clear benefits in cost, portability, and independence from mains power. Adopting this economical technology in eye-care task-shifting strategies could significantly increase the timely diagnosis of anterior-segment disease in low-resource settings, supporting blindness reduction efforts and advancing the goals of the Vision 2020[15] and Lancet Global Health Commission agendas[1].

Conclusion

Compared to the Slit lamp, OCOs found the Arclight device acceptable and time-saving, but technical limitations such as the inability to create a slit and its monocular design could be potential barriers to its use. In settings with limited access to slit lamps, the Arclight devices should be considered an alternative tool for diagnosing anterior eye segment diseases.

Abbreviations

OCO, Ophthalmic clinical officer; FGD, Focus group discussion; MNSH, Mulago National Super Specialised Hospital; LMIC, Low- and Middle-income countries.

Data Sharing Statement

The datasets used and analyzed in this study are available from the corresponding author upon reasonable request.

Ethical Approval

This research was a minimal risk study conducted in accordance with the Declaration of Helsinki. Ethical Approval was sought from the Mulago Hospital Research and Ethics Committee (MHREC 2021-58) and the Uganda National Council of Science and Technology (HS2007ES) before data collection. Administrative clearance was sought from the MNSH administration. The study team members are trained in the principles of Good Clinical Practice and the Protection of Human Subjects. Participants were informed about the aim of the study, the methods employed, the nature of their participation, and that anonymized responses and direct quotations would be published. Written informed consent was then obtained from all study participants. All information collected from participants during the research was kept strictly confidential with no name /personal identifiers of any person who took part in this study to be used in any report or publications resulting from the study. Participation in the study was voluntary.

Acknowledgment

We appreciate the administration of Mulago Hospital and its Ophthalmology department for approving the study to be carried out in their facility. We are further grateful to the patients and Ophthalmic clinical officers who participated in the study.

Author Contributions

All authors made a significant contribution to the work reported, whether that was in conception, study design, execution, data acquisition, analysis, interpretation, or all these areas; participated in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article was submitted; and accept responsibility for all aspects of the work.

Funding

The study was funded by the Makerere Research & Innovations Fund 3 (MAKRIF/CH/02/21). Matched funding was also secured from the University of St. Andrews in Scotland for purchasing Arclight medical devices. AWS was a research fellow of the MakNCD program(D43TW011401) supported by the Fogarty International Centre of the National Institutes of Health. JM was a Ph.D. student awarded under the Nurturing Genomics and Bioinformatics Research Capacity in Africa (BRECA) grant (U2RTW010672) from the Fogarty International Centre of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Disclosure

Dr. Andrew Blaikie is employed by the University of St Andrews, where Arclight has been commercialized under a subsidiary company within the University. He does not, however, have any direct financial gain from sales. The authors report no other conflicts of interest in this work.

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Hello, everybody—this is Gavin Verhey on behalf of the Pauper Format Panel. Today, we are making a change in Pauper. We want to walk you through the background of the change and why we’re making it.

We’ll start with the top line: High Tide is banned in Pauper. This ban takes effect immediately and will be live shortly on Magic Online.

Back in March, we unbanned High Tide as part of something new called trial unbans. The idea was that we could unban a card on a probationary basis, see how it performed, and then decide if we wanted to keep it off or return it to the banned list. This is a great way to investigate cards and potentially bring cards back into the format that people enjoy. At that time, we unbanned Prophetic Prism, which has been a success. It’s seen some play and helped decks like Urzatron, but ultimately it has been just fine. The format is very different than when Prophetic Prism was initially banned.

High Tide is a much more nuanced discussion.

At the time, we said this:

“Our hope is that the deck ends up, at best, an option in the metagame beneath the very best decks. If it ends up not being played after some experimentation, that’s a fine outcome. If it ends up fringe or playable but not in the best decks, that’s the ideal outcome. These scenarios will leave it unbanned.

“If it breaks through and enables one of the three most successful decks in the metagame, however, we will likely ban High Tide again at the end of the trial—having a kill-from-hand combo deck as one of the best three decks can be frustrating. Not every color can interact with that stretch super well.”

Event Results

First, let’s dive into data and results.

High Tide’s results started off slow as people began working to coalesce on the best versions. Eventually, players have refined the deck into a strong Psychic Puppetry and splice engine that casts High Tide and splices Psychic Puppetry onto Arcane spells to stay even or net mana, generating an immense amount of mana in a single long turn to eventually kill by looping Stream of Thought. This usually kills, when unimpeded, on turn four or five, but very occasionally on turn three.

There are a couple flexible card slots, but the majority of decklists tend to have near-identical main decks. Here’s a recent version that won a Magic Online challenge:

4 Brainstorm
1 Deep Analysis
1 Gigadrowse
3 Hidden Strings
4 High Tide
4 Ideas Unbound
13 Island
4 Merchant Scroll
4 Lórien Revealed
1 Muddle the Mixture
4 Peer Through Depths
3 Pieces of the Puzzle
4 Preordain
4 Psychic Puppetry
2 Reach Through Mists
2 Snow-Covered Island
2 Stream of Thought


1 Deep Analysis
2 Blue Elemental Blast
2 Dispel
1 Envelop
3 Fallaji Archaeologist
2 Gigadrowse
1 Muddle the Mixture
3 Snap

In terms of win rate, the deck started at just above 50% when it comes to its Magic Online win rate and didn’t have a large real-world showing at events like Paupergeddon—that’s more than fine. However, I’m really glad we took the extra time, because we have watched High Tide‘s success rate tick increasingly upward. It has crept some weeks on Magic Online to above 55%, sitting at or near the top of the metagame.

Unlike many other decks, it tends to vary a lot from week to week—despite its success, it has a smaller portion of the metagame and can be very matchup dependent (more on that later). It’s a deck that takes a large amount of play skill and experience to pilot optimally, and it’s very possible that it has taken time to slowly rise for that reason. While, as far as we can tell, the play rates online and in real life tend to be lower, historically complicated and slow combo decks tend to not show up as much in droves.

The success of High Tide alone debatably meets our threshold for banning. It is the other elements in concert with its success, however, that push it over the edge.

Problematic Gameplay and Tournament Logistics

High Tide is a card which certainly has a pedigree of slow turns—any longtime Legacy player can tell you about that. Some of that is not a surprise. However, Pauper’s version is likely even potentially more egregious than versions we’ve seen in the past.

It’s not uncommon for a High Tide combo turn to take ten or even fifteen minutes to execute, even in the hands of a skilled pilot. Unlike other formats which often have some big hammer card that helps make it clear to the opponent it’s time to pack things in, like a large Mind’s Desire, the incredibly incremental nature of the combo in Pauper means that things don’t really come to that major turning point. There is a version with a single Petals of Insight, so you can start generating infinite mana with it and enough copies of Psychic Puppetry, but many would say that’s suboptimal to play—drawing an ineffectual card with this deck can be the difference between winning and losing.

Speaking from my own personal experience, I have played a lot of High Tide now. I even played eleven rounds worth of it at in-person side events during this past Paupergeddon. I would be executing my combo for ten minutes and still not be sure if I was going to win the game. I had multiple opponents concede to me during moments where I thought I was more likely to fizzle. And while I don’t want to ascribe too much to an individual game or situation, the fact that the right play is always to fully force the opponent to play it out further compounds the time it takes.

The High Tide player will always try to combo off if they look like they’re about to lose the next turn, which means that you can expect some amount of a combo turn in every game of a match. This all boils down to a miserable gameplay experience, where the High Tide player takes up the majority of gameplay time while the other player sits there.

While it’s far from the only deck that can take a lot of time to execute—a deck like Familiars can also make games go long and monopolize the clock—at least in those cases you get to take another turn and play Magic. With High Tide, you will often watch for minutes on end with the result often being you don’t get another turn. Additionally, a deck like Familiars still leans on creatures for its combo, which the Pauper card pool is better suited to handle than something entirely from hand.

This additionally compounds in matters of tournament logistics. Because a single turn can take so long, even when plays are made at a reasonable pace, if the High Tide player begins their combo as the round is running out of time, it can cause the event to run over on time. This provides a poor event experience for everybody. While this happening is mostly situational, having it happen even just a couple times in an event can cause large delays.

While neither of these on their own are reasons for a ban—for example, we’re not taking action against Cycle Storm for its long turns—these factors in conjunction with it being a strong deck to play make it a serious problem and compound the issues.

Format Impact

While High Tide has not been the most played deck, that doesn’t mean its effects haven’t rippled across the entire format.

High Tide is a deck with extremely polar matchups. Many matchups, Game 1 is just a near-automatic loss, as the opponent has no interaction with the stack or hand, so unless they can kill by turn four, they’re relying on sideboarded games—unless your deck has a good Game 1 matchup against Tide, in which case Tide is probably in very rough shape.

To give some examples, against Mono-Blue Faeries, Tide’s worst matchup, some weeks its win rate has dipped below 20%. That is massively polar! While other matchups that don’t have Game 1 interaction have done the opposite. You sit down for Game 1 and you already often know who is going to win the first game (unless there’s a horrendous draw involved).

The result of this has been twofold.

The first is that decks that are advantaged or have a chance against High Tide in Game 1—Faeries, Tolarian Terror, Mono-Red—gain a large boost in the metagame. That’s not inherently bad. Decks becoming better because they beat up on other decks happens all the time. But it has contributed to the popularity of already popular decks and cemented Terror as a top deck.

The second piece, though, which is problematic, is that it has made it a lot more about decks racing past one another to see who can win first. Something a lot of players enjoy about Pauper is the incremental nature of the format. But if you’re trying to beat High Tide, you can either disrupt it or just try and run past it since it won’t interact with you. More decks doing the latter means the whole format gets more compressed and less interactive as people are zooming to die before High Tide’s fundamental turn.

Put another way: High Tide preys on midrange, meaning decks that can go under it but are weak to midrange become good counters. But we’ve been doing so much work over the past couple years to help slow down the format and make it more interactive: the more Pauper is about people just throwing cards at one another and seeing who wins as opposed to interactive games, generally the worse off it is. That doesn’t mean fast decks shouldn’t exist, but incentivizing the format to try to win quickly and interact very little is a negative.

Of course, after sideboarding, players gain access to options against and disruption for High Tide. Often it turns into how many sideboard cards you draw—though the deck is more resilient than many would give it credit. But this gameplay isn’t the best either when you have these very polar matchups where you lose Game 1 and then sideboard in a ton of cards to try and flip them. We’ve previously banned cards out of Mono-Red (like Monastery Swiftspear) for causing a level of polarity within the format that is lower than what High Tide is bringing to the table.

Despite the play rates being moderate, the impact on the format is outsized.

The High Tide Ban and Beyond

Ultimately, we had to ask ourselves the question, “Is High Tide making the format better or more enjoyable?” In the aggregate, and in looking at all the above reasons, the answer is no.

It’s a deck that has had outlier win rates, is hard to interact with, has caused large ripple effects, and creates a poor play and tournament experience.

Taking these elements into account together, we collectively made the decision to ban High Tide.

I want to stress that we are still happy with the experiment here. Trying something out, letting the community experiment with a card, creating discussion, and learning an outcome about a card that has essentially never been legal in the wider Pauper format is a positive result, even if the outcome was banning the card again. We have no plans for future trial unbans at this time, but I also wouldn’t be surprised to see us try it again in the future.

I will say that while we did need extra time to see how the format evolved with a deck this complicated and that took time to fully see the impact of, we do want to apologize for the moving window here. While each individual reason made sense—asking for more time over the summer to see how the deck played out and aligning with the regular announcement cadence once the window moved up two weeks—it still created a shifting date as players were trying to make plans and understand if they should invest time into learning this deck and acquiring the cards. This isn’t generally what you should expect from us, and we’ll try to not let this happen in any future trial unbans.

So, what about the other cards in the format?

Well, we looked across the whole format for any other changes to be made at this time. The deck which most caught our eye as potentially in the range of a ban is the Tolarian Terror decks. These decks have been consistently strong for most of this year and over the past six months have risen to the top in both play and win rate.

However, as mentioned earlier, we believe High Tide had an outsized impact on the format and what decks people chose. Many of the decks advantaged against Terror were ones that couldn’t compete with the speed of a deck like High Tide, and many sideboard slots that could have been used for Terror were taken up by hate for Tide. We want to monitor this now that we’ve removed High Tide as an arm of the format and see how it evolves from here.

The other deck we have had our eye on are the new Spy Combo decks that have been showing up. Here’s an example from a recent Magic Online Challenge, noting there is still experimentation with the exact mix of cards.

3 Avenging Hunter
4 Balustrade Spy
2 Dread Return
2 Elves of Deep Shadow
3 Forest
2 Gatecreeper Vine
4 Generous Ent
4 Land Grant
4 Lead the Stampede
2 Lotleth Giant
3 Masked Vandal
1 Mesmeric Fiend
4 Overgrown Battlement
3 Quirion Ranger
3 Saruli Caretaker
1 Snow-Covered Forest
4 Sagu Wildling
1 Swamp
3 Tinder Wall
3 Wall of Roots
4 Winding Way


2 Faerie Macabre
2 Fang Dragon
1 Flaring Pain
3 Healer of the Glade
3 Mesmeric Fiend
2 Nylea’s Disciple
2 Scattershot Archer

This fairly new hybrid combo deck can kill fast with Balustrade Spy setting up a lethal (or at least highly damaging) Dread Return on Lotleth Giant after milling most of its library; it also has the secondary plan of Walls accelerating into its big threats. It has definitely caught our eye as something to watch. Balustrade Spy and Dread Return both have a pedigree as extremely strong cards that can fuel problematic decks. However, there are still plenty of moments to interact with the combo and some clear sideboard options. We’ll want to continue watching to see how this develops, but it certainly looks a lot more appropriate in terms of overall impact than High Tide so far.

Overall, the format has looked healthy—which is partially why we were reserved about making this change. The impacts of a deck like High Tide are a lot less surface level than other problematic decks. Our hope is that this will nudge the format back a bit more toward interaction and drop a few percentage points off the decks that were preying on Tide being around. But, as with all things, we’ll have to wait and see.

Pauper Championships kick off this week on Magic Online, and I know we’ll eagerly be watching to see what happens both there and at Paupergeddon later this month out in Italy. As always, we’ll be out there reading everything you all have to write about this as well.

Thanks for reading, playing the format, and being up for trying something as experimental as a trial unban. It was a worthwhile experiment, and maybe we’ll try it again in the future.

This has been Gavin Verhey, now signing off on behalf of the Pauper Format Panel.

Alex Ullman
Alexandre Weber
Emma Partlow
Gavin Verhey
Mirco Ciavatta
Paige Smith
Ryuji Saito

Introduction

Vascular injuries in pediatric trauma cases are relatively rare, representing just 0.6% to 1.4% of all injuries in children.^1,2 Despite their rarity, the serious implications of these injuries make them a major concern in trauma management. Pediatric vascular trauma presents unique challenges due to the smaller diameter of blood vessels, increased likelihood of vasospasm, limited intravascular volume, and the necessity to accommodate future vessel growth. Moreover, the long-term viability of vascular repairs and the diagnostic complexity of such injuries add further difficulty to their treatment.³ These injuries can be difficult to detect, as vasospasm and concurrent trauma may mask their presence, making swift diagnosis and treatment critical. In younger children, the typical signs of vascular injury—such as visible pulsatile bleeding—are often less noticeable.⁴ In Somalia, due to the high prevalence of terrorism and conflict-related violence, blast and gunshot injuries are particularly common.⁵ The ongoing conflict in Somalia dates back to the collapse of Siad Barre’s regime, with varying levels of intensity over the years. Its primary drivers are terrorism and inter-clan disputes.⁶ Despite this context, there is a lack of comprehensive studies detailing the patterns, causes, surgical strategies, and outcomes of pediatric vascular injuries within Somali conflict zones. Our hospital, located in Mogadishu—the capital of Somalia—was established through a bilateral agreement between the health ministries of Somalia and Türkiye, aimed at strengthening collaboration in healthcare and medical services. It serves as a key referral center for vascular surgery across the country, receiving patients from both Mogadishu and other regions with traumatic vascular injuries.

This five-year retrospective study seeks to address the existing knowledge gap by examining pediatric vascular trauma cases treated at selected Somali hospitals. The study’s objectives include documenting the mechanisms of injury, anatomical sites affected, types of surgical interventions performed, and patient outcomes such as limb salvage and mortality. In conflict-affected systems, delayed prehospital transport, limited imaging, and scarce graft materials compound ischemia time and increase the risk of limb loss. We aimed to quantify patterns and mechanisms of injury, describe operative strategies, and report limb-salvage and mortality, while identifying modifiable system factors (eg, time-to-care).

Methods

Study Design and Setting

This was a retrospective cohort study conducted at Mogadishu Somali-Türkiye Training and Research Hospital, the national referral center in Somalia. The study period spanned five years, from April 2019 to April 2024. Data were extracted from the hospital’s FONET electronic medical records system and are available from the corresponding author upon reasonable request.

Participants

Eligible participants included all pediatric patients (≤18 years) presenting with clinically or radiologically confirmed arterial or major venous injuries due to trauma and managed at our center. Exclusion criteria were iatrogenic catheter-related injuries, and cases with missing operative or outcome data.

Data Collection and Variables

A single investigator performed the retrospective review and collected socio-demographic (age, sex, time to admission), clinical, and operative data. Mechanisms of injury were categorized as penetrating trauma (gunshot wounds, stabbings, glass cuts, saw-related injuries, shrapnel, or blast trauma) or blunt trauma (falls, motor vehicle accidents, or sports injuries). Associated injuries recorded included bone fractures, nerve injuries, and compartment syndrome. Complications of interest included infection, graft failure, limb amputation, and in-hospital mortality. All patients underwent initial evaluation by the cardiovascular surgery team upon admission. Resuscitation followed Advanced Trauma Life Support (ATLS) principles. Diagnosis of vascular injury was based on clinical examination supplemented by: handheld Doppler; color Doppler ultrasonography; computed tomography angiography (CTA) in hemodynamically stable patients with equivocal findings; or immediate surgical exploration in the presence of “hard signs” of vascular injury (pulsatile hemorrhage, expanding hematoma, bruit/thrill, or distal ischemia). Bone fractures were confirmed by plain radiographs when clinically indicated. Surgical management followed standard vascular repair principles. After vascular exposure, proximal and distal control was established, and systemic heparin (100 IU/kg) was administered unless contraindicated. Inflow and outflow were assessed, with thrombectomy performed when necessary. Definitive repair included: primary repair or end-to-end anastomosis when feasible; interposition grafting with the great saphenous vein (preferred), or cephalic/basilic veins for brachial artery injuries; polytetrafluoroethylene (PTFE) grafts when autologous vein was unavailable. Orthopedic stabilization was performed following revascularization to minimize ischemia time. Four-compartment fasciotomy was performed when reperfusion was delayed or compartment syndrome was suspected. Concomitant nerve injuries identified intraoperatively were repaired as appropriate. For patients presenting after >6 hours or with reduced distal mobility, the decision between revascularization and primary amputation was guided by intraoperative assessment of muscle viability via fasciotomy and contractility testing. The statistical analysis of this study was performed with the use of Statistical Package for Social Sciences Version 24.0 software (SPSS Inc., Chicago, IL, USA).

Ethical Approval

Ethical approval was obtained from the Mogadishu Somali Türkiye Training and Research Hospital’s institutional review board MSTH/16842 reference number available upon request. The study adhered to the principles of the Declaration of Helsinki and local ethical guidelines. Informed consent was obtained from each patient’s legal guardian.

Results

Among the 54 patients, 38 (70.4%) were aged between 13 and 18 years. The majority were male, with 45 patients (83.3%) being boys. The most common time for admission was during the evening hours from 6:00 PM to midnight, when 24 patients (44.4%) were hospitalized. In terms of injury mechanisms, penetrating trauma accounted for the majority of cases, affecting 44 patients (81.5%). These injuries included gunshot wounds, blast injuries, stab wounds, penetrating saw injuries, glass lacerations, and shrapnel wounds. Blunt trauma was less common, seen in 10 patients (18.5%), resulting from motor vehicle accidents, falls from heights, and sports-related blunt injuries such as those sustained during football, as shown in Table 1. The most frequently injured sites were the upper and lower limbs. The brachial artery in the upper limb was involved in 14 cases, highlighting its vulnerability, while the superficial femoral artery in the lower limb was affected in 12 cases. Venous injuries were less frequent but mainly involved the femoral vein, with 4 cases. Notable injuries were also recorded in the head and neck region, including 4 injuries to the common carotid artery and 3 to the internal jugular vein. Overall, arterial injuries (56 cases) were more common than venous injuries (10 cases), as detailed in Table 2. Regarding treatment, primary repair was the most frequently used method, performed in 22 patients (40.7%). Vein graft interposition was used in 19 patients (35.2%), and a combination of primary repair and vein grafting was applied in 6 patients (11.1%), reflecting a tailored approach in some cases to improve outcomes. Two patients (3.7%) received vein grafts with fasciotomy, and one patient (1.9%) underwent vein grafting combined with a muscle flap, indicating more complex interventions. Conservative management was chosen for two patients (3.7%), with an additional two patients (3.7%) receiving conservative treatment alongside fasciotomy, suggesting that even non-surgical approaches sometimes required intervention for complications, as shown in Table 3. A notable 23 patients (42.6%) had no associated injuries. Among those with additional trauma, fractures were the most common, with 14 patients (25.9%) sustaining upper extremity fractures and 11 patients (20.4%) having lower extremity fractures. Nerve injuries were present in 4 patients (7.4%) affecting the upper extremity, and one patient (1.9%) developed compartment syndrome. There was also one case (1.9%) involving both a lower extremity fracture and nerve injury, as outlined in Table 4. Most patients (49, or 90.7%) experienced no complications following treatment. However, a small number faced adverse outcomes: 3 patients (5.6%) developed infections, one patient (1.9%) required amputation, and one patient (1.9%) died due to their injuries, as detailed in Table 5.

Table 1 Patient Demographics

Table 2 Site of Injury and Related Vessels

Table 3 Management of the Patients

Table 4 Associated Injuries

Table 5 Complications Resulted from the Injury

Discussion

In this study, the majority of patients were male (83.3%), with 70.4% between the ages of 13 and 18 years. This aligns with trends observed in other studies, where male pediatric patients are more frequently affected by traumatic vascular injuries, especially in conflict or violence-related settings.^7,8 In addition, there was an unusual penetrating vascular injury caused by a wooden stick.⁹ This pattern is consistent with the higher rates of violence in regions such as Somalia, where these injuries are commonly encountered in pediatric trauma centers.^7,8 The evening hours (6:00 PM to 12:00 AM) accounted for the majority of hospital admissions, which suggests that these injuries are often a result of violent events occurring during these times. Regarding injury mechanisms, the study found a predominant pattern of penetrating trauma, with 81.5% of patients sustaining injuries from firearms, explosive devices, and shrapnel. This is consistent with other studies that have reported a higher prevalence of penetrating injuries in conflict zones.^7,10 Although blunt trauma accounted for 18.5% of cases, it is often associated with more complex multisystem involvement, complicating both diagnosis and treatment.¹⁰ Prompt recognition of blunt trauma facilitates early intervention, thereby minimizing complications.¹¹ Furthermore, injuries related to motor vehicle accidents, falls, and sports-related trauma were present but less common, mirroring findings from other trauma studies.^12,13 The upper and lower limbs were the anatomical regions most commonly affected, with the brachial artery in the upper limb (14 cases) and the superficial femoral artery in the lower limb (12 cases) being the most frequently injured vessels. This emphasizes the particular susceptibility of these arteries in pediatric trauma.^10,14,15 In contrast, venous injuries were less common, with the femoral vein being most frequently injured. The head and neck region, though less commonly injured, still represented significant concerns, particularly for the common carotid artery and internal jugular vein (4 cases and 3 cases, respectively). Our rate of carotid and jugular injuries parallels findings from Villamaria et al, who reported similar distributions in wartime pediatric cohorts from Iraq and Afghanistan. The high frequency of arterial injuries, particularly in the lower limbs, is consistent with other studies where the lower extremities were the most commonly injured sites.^10,12 Surgical management of vascular trauma predominated, with primary repair being the most commonly utilized approach (40.7%), followed by vein graft interposition (35.2%). The choice of surgical strategy was tailored to the nature and complexity of the injuries. Multiple arterial injuries were observed in 3.7% of cases, which compounded surgical complexity. Complex cases were addressed with a combination of primary repair and vein graft interposition (11.1%), while vein graft with fasciotomy and muscle flap were used in more challenging cases (3.7% and 1.9%, respectively). Conservative management was used for a small subset of patients (3.7%), particularly those who were hemodynamically stable with no clear signs of vascular injury. This mirrors the management trends observed in similar pediatric vascular trauma series, where open surgical repair remains the most frequently used approach.^12,13,16 Fractures were the most prevalent associated injuries, especially in the upper and lower limbs. Additionally, nerve injuries were observed in several cases, and one patient developed compartment syndrome. The coexistence of fractures with vascular injuries often presents a challenge, complicating both surgical management and postoperative recovery. These findings align with previous research that underscores the complexity of pediatric vascular trauma.^10,12 Most patients (90.7%) did not experience any postoperative complications. However, a small proportion developed infections (5.6%) or required limb amputation (1.9%). The most severe outcome observed in this group was the death of one patient due to a critical vascular injury. Bramparas et al reported a 13% mortality rate in their study of pediatric vascular trauma cases from the American College of Surgeons National Trauma Data Bank. This highlights the serious nature of pediatric vascular injuries, especially those involving major arteries such as the femoral artery, which has been associated with increased mortality in other studies.^1,16

The significant peak in hospital admissions for pediatric vascular injuries in 2023, as reflected in the time series graph, suggests a potential increase in either the incidence of these injuries or improvements in detection and reporting mechanisms.

Our study demonstrates a remarkably high limb salvage rate of 98.1% despite the constraints of working in a conflict-affected, resource-limited setting, with an overall mortality of only 1.9%. These outcomes underscore the critical influence of system-level factors such as time-to-care, referral delays, and the availability of blood products on patient survival and limb viability. Compared with multicenter series from the United States and Europe, where penetrating trauma accounts for a smaller proportion of pediatric vascular injuries and repair strategies are similar, our cohort reflects the distinctive burden of conflict settings with a higher share of penetrating mechanisms and greater reliance on autogenous vein grafts. The findings highlight several actionable priorities: strict adherence to a standardized “hard signs → operating room” pathway, lowering thresholds for fasciotomy in delayed or high-risk reperfusion, systematic autologous vein harvesting protocols, establishment of a regional referral hotline, and creation of a trauma registry to strengthen coordinated care. Nonetheless, this study is limited by its retrospective, single-center design and the lack of long-term data on graft patency or functional outcomes. Future work should focus on prospective, multicenter registry development incorporating 6–12-month follow-up with duplex ultrasonography and validated functional measures such as the Pediatric Quality of Life (PedsQL) inventory and gait assessments to better define recovery trajectories and optimize outcomes for this vulnerable population.

Conclusion

Pediatric vascular trauma in Somalia is predominantly penetrating and closely linked to conflict-related mechanisms such as gunshot, blast, and shrapnel injuries, though unusual mechanisms such as wooden stick penetration were also observed. Despite severe injury patterns and resource limitations, timely surgical intervention achieved excellent limb salvage (98.1%) with very low mortality (1.9%). These findings highlight the critical importance of early recognition, rapid referral, and standardized management protocols to optimize outcomes. Strengthening system-level factors—including blood-bank capacity, referral networks, fasciotomy readiness, and vascular training—will be essential in reducing preventable limb loss and mortality in conflict-affected regions. Future multicenter prospective studies with long-term follow-up, including graft patency and functional outcomes, are warranted to guide evidence-based improvements in pediatric vascular trauma care.

Data Sharing Statement

The data for this study were obtained from the hospital’s FONET electronic system and can be accessed from the corresponding author upon reasonable request.

Author Contributions

All authors made a significant contribution to this work, whether that is, in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

The authors declare that they have no funding source for this research.

Disclosure

The authors declare that they have no conflicts of interest.

References

1. Barmparas G, Inaba K, Talving P, et al. Pediatric vs adult vascular trauma: a national trauma databank review. J Pediatr Surg. 2010;45(7):1404–1412. doi:10.1016/j.jpedsurg.2009.09.017

2. Corneille MG, Gallup TM, Villa C, et al. Pediatric vascular injuries: acute management and early outcomes. J Trauma. 2011;70(4):823–828. doi:10.1097/TA.0b013e31820d0db6

3. Callcut RA, Mell MW. Modern advances in vascular trauma. Surg Clin North Am. 2013;93(4):941–961. doi:10.1016/j.suc.2013.04.010

4. Lyons NB, Berg A, Collie BL, et al. Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center. Trauma Surg Acute Care Open. 2024;9(1):1386. doi:10.1136/tsaco-2023-001263

5. Tahtabasi M, Er S, Karasu R. Bomb blast: imaging findings, treatment and clinical course of extremity traumas. BMC Emerg Med. 2021;7:1–10.

6. Bade ZA. Understanding Somali Confict: causes, consequences and strategies for peace-building. Dev Ctry Stud. 2021.

7. Ab Rahman N, von Delft D, Numanoglu A, Mohammad Aidid E, Arnold M. A decade of managing pediatric major traumatic vascular injuries: insights from a referral center. Pediatric Surg Int. 2024;40(1):1–9. doi:10.1007/s00383-024-05887-7

8. Hussein AM, Ali AA, Ahmed SA, Mohamud MF, Ahmed MA, Kizilay M. Our experience with blast and gunshot induced traumatic vascular injuries at Somalia’s major vascular referral center. Sci Rep. 2024;14(1):13004. doi:10.1038/s41598-024-63686-5

9. Ali AA, Mohamed AO, Ahmed FM, Abdi HK, Keinan HB, Ahmed SA. Unusual mechanism of vascular trauma: femoral artery penetration by wooden stick and delayed repair case report. Int J Surg Case Reports. 2025;26:111872. doi:10.1016/j.ijscr.2025.111872

10. Perea LL, Hazelton JP, Fox N, et al. Pediatric major vascular injuries a 16-year institutional experience from a combined adult and pediatric trauma center. Pediatr Emerg Care. 2018;37(8):403–406. doi:10.1097/PEC.0000000000001642

11. Ali AA, Hussein AM, Albay E, Siyad AA, Hassan MO, Ahmed SA. A blunt traumatic giant pseudoaneurysm of the brachiocephalic artery: a case report from Somalia. Int J Surg Case Reports. 2024;116:109329. doi:10.1016/j.ijscr.2024.109329

12. Wahlgren CM, Kragsterman B. Management and outcome of pediatric vascular injuries. J Trauma Acute Care Surg. 2015;79(4):563–567. doi:10.1097/TA.0000000000000812

13. Eslami MH, Saadeddin ZM, Rybin DV, et al. Trends and outcomes of pediatric vascular injuries in the United States: an analysis of the national trauma data bank. Ann Vasc Surg. 2019;56:52–61. doi:10.1016/j.avsg.2018.09.006

14. Kayssi A, Metias M, Langer JC, et al. The spectrum and management of noniatrogenic vascular trauma in the pediatric population. J Pediatr Surg. 2018;53(4):771–774. doi:10.1016/j.Jpedsurg.2017.04.015

15. Morão S, Ferreira RS, Camacho N, et al. Vascular trauma in children—review from a major paediatric center. Ann Vasc Surg. 2018;49:229–233. doi:10.1016/j.avsg.2017.10.036

16. Prieto JM, Van Gent JM, Calvo RY, et al. Evaluating surgical outcomes in pediatric extremity vascular trauma. J Pediatr Surg. 2020;55(2):319–323. doi:10.1016/j.surg.2023.04.060

Introduction

Selective laser trabeculoplasty (SLT) and neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy are two of the most commonly performed ophthalmologic procedures.^1,2 Approximately 150,000 United States Medicare beneficiaries with open angle glaucoma undergo SLT procedures each year^3–5 and the incidence of Nd:YAG laser capsulotomy increases from 6% at one year to 38% at nine years following cataract extraction.⁶ In each of these procedures, focused laser energy is applied to the target tissue – the trabecular meshwork of eyes with glaucoma to improve aqueous outflow and reduce intraocular pressure (IOP)⁵ in SLT, and the opacified posterior lens capsule to surgically create an opening through which visual acuity is improved in Nd:YAG capsulotomy.⁷ For each procedure, a reusable or single-use disposable ophthalmic contact lens improves the surgeon’s visualization of the target tissue, thereby enabling more precise application of laser energy.⁸

Concerns have arisen over the spread of infectious diseases during procedures, and though transmission of human immunodeficiency virus (HIV), Hepatitis C, Hepatitis B, and prion diseases via these laser contact lenses has not been documented, cases of adenovirus and herpes simplex virus type 1 (HSV-1) have been linked to repeat-use tonometry tips.^9–12 Consequently, ophthalmology practices attempt to mitigate the risk of infection by disinfecting reusable lenses or opting for single-use, disposable alternatives.^5,13–17

Single-use, disposable plastic products in health care unfortunately constitute large volumes of plastic waste and create considerable expense.^9,13,18,19 Disposable lenses and tips have become increasingly popular in recent decades^13,20 with 59.1% of ophthalmology practices in the United Kingdom using disposable tonometry tips.¹³ Several authors, however, have reported that disposable lenses are functionally inferior to their reusable counterparts, are prone to damage, and may produce an inferior treatment effect.^5,21–23

Disinfection techniques effectively prevent transmission of infections from reusable lenses and tips, with the American Academy of Ophthalmology reporting that sterilization with a dilute solution of sodium hypochlorite eliminates Adenovirus 8 and HSV-1.²⁴ Further supporting the use of reusable lenses is the persistent risk of infection with disposable tonometer prisms. In the Sussex Eye Hospital, 50% of providers touched the disposable tonometer prism before measuring IOP, and subsequent cultures grew Staphylococcus epidermidis, Staphylococcus aureus, and Bacillus species.²⁵ Thus, it is not clear that disposable lenses and tips prevent infection relative to their reusable counterparts.

Since single-use disposable lenses create substantial economic and environmental burdens, and are less effective, understanding the infection risks associated with reusable ophthalmic lenses becomes an important health and economic issue. This study aims to better understand the rate of conjunctivitis and/or keratitis due to reusable laser lenses that are cleaned with isopropyl alcohol, followed by soap and water, and thorough drying, after SLT and Nd:YAG laser capsulotomies.

Methods

Cohort and Consent

A retrospective chart review included all eyes undergoing a Nd:YAG capsulotomy or SLT procedure with reusable laser lenses between January 1, 2014, and December 31, 2023, at a single, nonprofit academic medical center (Mayo Clinic, Jacksonville, FL). During the study period, only reusable lenses were used. The study protocol was approved by the Mayo Clinic Institutional Review Board (IRB) on August 12, 2024 (IRB #24-006702), and informed consent was waived due to the retrospective study design. This study complies with the tenets outlined in the Declaration of Helsinki and adheres to the Health Insurance Portability and Accountability Act regulations.

Patient Data

For each procedure, patient demographic data (age at the date of the Nd:YAG laser capsulotomy and/or SLT procedure, race, and biological sex), procedure type, physician name, date of procedure, laterality, history of conjunctivitis and/or keratitis, and incidence of conjunctivitis and/or keratitis within two weeks post-procedure were recorded. Data from three ophthalmologists (R.D.T., S.K.D., D.D.M.) were included in the analysis. At the completion of the procedure, patients were instructed to contact the office immediately if they developed pain, blurred vision, redness, irritation, photosensitivity, discharge, photopsias, floaters, “curtains”, or “clouds”. For each patient who contacted the office with any of these symptoms, they were examined promptly (within 24 hours). For all Nd:YAG capsulotomy and SLT lasers, no topical antibiotics were instilled before or after the procedures. Prior to and after all Nd:YAG capsulotomy lasers, neither topical corticosteroids nor non-steroid anti-inflammatory drugs were instilled or prescribed. Prior to and after all SLT procedures, no topical corticosteroids were used. One ophthalmologist (R.D.T.) prescribed topical ketorolac 0.5% four times per day for one week after SLT. All patients received follow-up appointments approximately four weeks after each procedure.

Post-Use Sterilization of Reusable Lenses

Reusable lenses were thoroughly cleaned after each procedure with 70% ethyl alcohol followed by soap and water for at least two minutes. The lenses were then completely dried using sterile wipes prior to the next use.

Statistical Analysis

Data were analyzed with the SPSS 22.0 program (SPSS Inc., Chicago, IL). Demographic variables were expressed as percentages. The primary outcome was the incidence of conjunctivitis and/or keratitis (diagnosed by the treating surgeon) within the first two weeks after the laser procedure. The keratitis and conjunctivitis rates were calculated by dividing the total number of affected eyes by the total cohort size. For each new case of keratitis and/or conjunctivitis, the dates when symptoms first appeared and when they resolved were documented.

A cost analysis was conducted to assess the economic implications of using reusable versus disposable lenses for both laser procedures. A break-even analysis was used, calculating the per-procedure cost of reusable lenses by dividing the total cost of two lenses of each type ($755 × 2 for Nd:YAG laser capsulotomy; $719 × 2 for SLT) by the number of corresponding procedures and adding the sterilization cost per use. The analysis assumed that cleaning time incurred minimal cost and that reusable lenses required no replacement over a 10-year period. For purposes of this analysis, the per unit cost of each disposable Nd:YAG lens and SLT lens was $16.70 per lens. A medical waste analysis was performed incorporating the weight of the disposable lens along with the individual plastic packaging and the box (one for every ten disposable lenses).

Results

Baseline Characteristics

A total of 2285 eyes from 1363 patients were included in this study (Table 1). The mean age (standard deviation) of treated patients was 71.6 (7.4) years with most being female (57%) and Caucasian (83%). A low percentage of treated eyes (0.4%; four eyes with non-specific conjunctivitis and five eyes with chronic allergic conjunctivitis) had a history of conjunctivitis but none were active at the time of the laser surgery and none had a history of prior keratitis. A total of 1372 Nd:YAG laser capsulotomies and 913 SLT procedures were performed, accounting for 60% and 40% of the study population, respectively.

Table 1 Demographic Characteristics

Cases of Keratitis and/or Conjunctivitis

Of the 2285 eyes, one developed conjunctivitis within the two-week window after undergoing a Nd:YAG capsulotomy. Symptoms began within 24 hours of the laser and the patient was examined on the second post-operative day. A diagnosis of medicamentosa was made and the patient was treated with preservative-free lubricating ophthalmic eye drops with resolution of symptoms within five days. No cases of keratitis were seen.

Cost Analysis

Cost analysis results are presented in Table 2. The per-unit cost of a disposable lens was $16.70 for both Nd:YAG laser capsulotomy and SLT, while reusable lenses were priced at $755 (Nd:YAG) and $719 (SLT). Over the 10-year study period, two reusable lenses of each type were repeatedly used and remained fully functional without requiring replacement. As the manufacturer did not specify expiration or usage limits, reusable lens costs were amortized across the entire study duration. Reprocessing required minimal resources: one 70% isopropyl alcohol wipe ($0.011 per wipe), one pump of liquid soap (estimated $0.008 per wash), a 10-second tap water rinse (0.002 gallons at $0.005/gallon = $0.00001), and one paper tissue ($0.01 per tissue), resulting in an estimated supply cost of $0.03 per use. Manual cleaning, completed by clinical staff in under one minute, required no specialized equipment, detergents, or autoclaving, and did not disrupt clinic workflow. Break-even analysis indicated that reusable lenses became more cost-effective than disposable lenses after approximately 86 SLT procedures and 91 Nd:YAG laser capsulotomies (Table 2).

Table 2 Cost Analysis

Medical Waste

In terms of medical waste, a single Nd:YAG procedure produced approximately 12.1 g of waste with a disposable lens and 3.0 g with a reusable lens. Similarly, an SLT procedure generated 17.8 g and 3.0 g of waste with disposable and reusable lenses, respectively. Across 1372 Nd:YAG capsulotomies and 913 SLT procedures, the total waste from disposable lenses was estimated at 32.9 kg, compared to 6.9 kg for reusable lenses, which represents a 79% reduction with reusable lenses during the study period.

Discussion

This study identified low post-operative keratitis (0/2285; 0%) and conjunctivitis rates (1/2285; 0.044%) in patients undergoing SLT or Nd:YAG laser eye surgeries with reusable ophthalmic laser lenses. Because symptoms occurred within one day of the procedure, the single case of conjunctivitis was determined to be secondary to medicamentosa (ocular inflammation from ophthalmic drops with preservatives given prior to the procedure) and was not deemed to be infectious.²⁶ The contralateral eye, which also underwent Nd:YAG laser capsulotomy using preservative-free topical drops, did not develop conjunctivitis, and the patient’s history of chronic dry eye syndrome likely contributed to the risk of an adverse reaction. The two week time window was used since symptoms of infectious conjunctivitis and keratitis present during this time period.²⁷

The near total absence of keratitis and conjunctivitis in this study suggests that reusable ophthalmic laser lenses do not constitute a significant risk for infection after laser procedures and that transitioning to single-use, disposable ophthalmic lenses may be unnecessary. Given the lack of evidence linking reusable lenses to an increased infection risk, the benefits of disposable lenses may not outweigh their associated drawbacks, such as increased susceptibility to laser damage and reduced treatment efficacy.^5,21–23

Reusable ophthalmic lenses are generally classified as semi-critical equipment, which includes devices that come into contact with mucous membranes or nonintact skin.^28,29 As such, high-level disinfection, commonly achieved using hydrogen peroxide, glutaraldehyde, peracetic acid with hydrogen peroxide, or ortho-phthalaldehyde, with a minimum exposure time of 12 minutes, is recommended.^29,30 In contrast, noncritical equipment, which contacts only intact skin, requires low-level disinfection³¹ with a minimum exposure of one minute to alcohol, sodium hypochlorite, or quaternary ammonium compounds.^30,31 Since reusable capsulotomy and trabeculoplasty lenses rarely cause infection after low-level disinfection, it is reasonable to consider reclassifying them from semi-critical equipment requiring high-level disinfection to noncritical equipment requiring low-level disinfectants.

A recent study at the Mayo Clinic in Rochester, MN, analyzed laser-induced damage to disposable gonioscopy lenses used during 113 SLT procedures. Damage was found in 6.7 ± 7.5% of the total lens area, with 73% of lenses exhibiting damage to more than 1% of the area.⁵ The area of lens damage correlated with both total laser energy and mean energy per application, whereas patient and physician factors were not significant.⁵

Three small studies also support a strong association between laser and damage to single-use gonioscopy lenses.^21–23 Damage to the reflective coating was noted after SLT in 16 of 17 (94%) disposable gonioscopy lenses in one study,²¹ 2 of 2 (100%) in a second,²² and 6 of 6 (100%) in a third.²³ The high susceptibility of disposable lenses to laser damage was thought to be attributed to their design, which consists of an external, unsupported silver coating over the gonioprism. In contrast, reusable lenses feature a first-surface anti-reflective mirror with the silver coating reinforced by a glass slide.²² Additional design differences of disposable lenses include increased adhesion to the ocular surface, which can make post-procedure removal challenging and can lead to corneal injury.

Damaged lens mirror coatings can scatter light, distort beams, and reduce delivery of laser energy to the trabecular meshwork, which can diminish efficacy.²¹ Two studies have examined the relationship between single-use gonioscopy lens damage and post-operative IOP reduction.^5,21 One found an association between increased lens damage and decreased IOP reduction,⁵ while the other found no significant difference in IOP-reducing efficacy between disposable and reusable gonioscopy lenses following SLT.²¹ The different results noted in these two studies may result from the definition of lens damage, since the latter study measured the number of affected reflective coatings,²¹ and the former quantified the total ablated area of the reflective coating.⁵ Repeated exposure to disinfectants can damage reusable lenses but this can be mitigated by avoiding acetone and peroxide,²⁸ routinely inspecting reusable lenses, and replacing them at the first sign of damage. This strategy can result in significant cost savings.⁹

There is an economic burden imposed by single-use ophthalmic products. A district general hospital in the United Kingdom found that disposable tonometry tips incur an excess cost of at least £15,000 annually (approximately $17,330 USD),¹³ and an ophthalmology outpatient service of comparable size to ours in the United States reported that single-use equipment, including gonioscopy lenses and applanation tonometry tips, generates an additional $65,185 in costs and 109.6 kg of plastic waste per year.⁹ In our analysis, reusable ophthalmic laser lenses became more cost-effective than disposable alternatives after 86 SLT procedures and 91 Nd:YAG capsulotomies, highlighting their potential for substantial cost savings. Reusable lenses also reduced medical waste, generating only 3.0 g per procedure compared to 12.1 g for Nd:YAG capsulotomies and 17.8 g for SLTs with disposable lenses. Across all procedures, this corresponded to a 79% reduction in total waste (6.9 kg vs 32.9 kg). These findings support reusable lenses as a cost-efficient and environmentally sustainable alternative in high-volume clinical settings, aligning with institutional goals to reduce healthcare costs and environmental impact without compromising clinical efficiency or patient safety.

Disposing of large quantities of plastic waste and consuming non-renewable petroleum resources, consequences of the increased use of plastic consumables, poses significant environmental concerns.³² Non-biodegradable plastic products accumulate in terrestrial, saltwater, and marine environments, where they adversely affect wildlife by releasing toxic chemicals and persistent organic pollutants. Wildlife can be injured by ingesting or becoming entangled by these pollutants.^9,33,34 Considering the substantial financial and environmental impact of single-use disposable lenses and the lack of evidence supporting their prevention of infections, their routine use should be re-evaluated. Alternatives to disposable lenses, such as reusable trabeculoplasty and capsulotomy lenses that are less susceptible to laser-induced damage, may offer an equally safe and more cost-effective and sustainable option.⁵

To our knowledge, this is the first study to evaluate the post-procedure incidence of keratitis and conjunctivitis associated with reusable gonioscopy and capsulotomy lenses, thereby addressing an unmet need in the literature. Study limitations include the single-center design and the homogeneity of the patient population. The retrospective nature of this study may have led to an underestimation of mild or self-limiting infections. Additionally, assumptions made in the cost analysis, including minimal labor costs and no lens replacement over 10 years, may have led to an underestimation of the true cost of reusable lenses. The study’s strengths lie in its large sample size and long-term data, which provide valuable insights into the safe and effective use of reusable ophthalmic lenses.

Conclusion

Single-use disposable ophthalmic lenses impose significant economic and environmental burdens without offering a clear safety advantage, emphasizing the importance of understanding infection risks associated with reusable ophthalmic lenses. In this study of 2285 eyes undergoing Nd:YAG capsulotomy (1372 eyes) and SLT (913 eyes) with reusable lenses, only one case of postoperative conjunctivitis (0.044%), secondary to medicamentosa, occurred within two weeks, with no cases of keratitis. Reusable lenses became more cost-effective after approximately 86 SLT and 91 Nd:YAG capsulotomy procedures, and reduced medical waste by 79%. Given the negligible infection risk, substantial cost savings, and environmental benefits, the routine use of disposable ophthalmic lenses warrants reconsideration.

Data Sharing Statement

The author’s institution does not permit data sharing. Other queries and requests should be directed to the corresponding author (D.D.M.).

Consent for Publication

This study was carried out in accordance with the tenets of the Declaration of Helsinki. Approval from the Mayo Clinic Institutional Review Board was obtained. All data has been deidentified, and no personal identifying information is contained within this report.

Acknowledgments

We would like to thank Ms. Joyce Baker for her generous contributions to the Department of Ophthalmology, Mayo Clinic, Florida, United States.

Author Contributions

All authors made a significant contribution to the work reported (conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas); took part in drafting, revising or critically reviewing this article; gave final approval of the version to be published and agreed on the journal the article was submitted to; and agree to be accountable for all aspects of the work.

Disclosure

No funding or grant support was obtained. All authors report no conflicts of interest in this work.

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NEW YORK, Nov. 10, 2025 /PRNewswire/ — Gartner^®, a company that delivers actionable, objective insights to executives and their teams, has recognized Deloitte as a Leader in the 2025 Gartner^® Magic Quadrant^™ for Digital Experience Services. Deloitte also scored highest in all five Use Cases in the accompanying 2025 Gartner Critical Capabilities for Digital Experience Services report.

Deloitte is placed in the Leaders Quadrant in the Gartner^® Magic Quadrant^™ for Digital Experience services, positioned highest on the “Ability to Execute” axis. Deloitte was also positioned furthest on the “Completeness of Vision” axis.

“For Deloitte Digital, this recognition from Gartner reflects our commitment to creating world-class customer, employee and citizen experiences that enable high-performing brands and drive profitable growth,” said Mark Lush, Deloitte Global Consulting Services Customer Offering Portfolio leader and Global Head of Deloitte Digital. “Our deep industry knowledge, advanced engineering, and Agentic AI capabilities enable our clients to confidently navigate today’s challenges and seize tomorrow’s opportunities for competitive advantage.”

Deloitte was the highest scoring provider across all Use Case categories in the new Critical Capabilities report. The report assessed how Deloitte delivers across five Use Cases: Experience Design, Experience Solution Implementation, Experience Solution Operations, Content & Creative Services, and Marketing Services. 

“We are proud to be recognized as a Leader, especially in our Ability to Execute. This is an important part of our culture at Deloitte – to consistently deliver meaningful, impactful outcomes for our clients,” said Mike DeLone, Customer Offering Portfolio leader, Deloitte Consulting LLP. “Our industry depth, strategic insights, and digital transformation services help our clients envision what’s possible, and our teams’ focus on execution enables them to exceed their growth ambitions.”

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The UK is to investigate whether hundreds of Chinese-made buses can be controlled remotely by their manufacturer, amid increasing concerns over Beijing’s involvement in British infrastructure.

The Department for Transport and the National Cyber Security Centre are examining whether buses made by Yutong could be vulnerable to interference.

A spokesperson for the Department for Transport said: “We are looking into the case and working closely with the UK’s National Cyber Security Centre to understand the technical basis for the actions taken by the Norwegian and Danish authorities.

“The department takes security issues extremely seriously and works closely with the intelligence community to understand and mitigate potential risks.”

Yutong began as the Zhengzhou Bus Repair Factory in 1963 in the Central China province of Henan. It says it has exported nearly 110,000 buses to more than 100 countries, capturing more than 10% of the global market.

In the UK, its buses are used in Bristol, Essex, Leicester, Nottingham, south Wales and South Yorkshire, among other locations.

However, an investigation in Norway by Oslo’s public transport service, Ruter, found that Yutong buses could theoretically be “stopped or rendered inoperable” by the manufacturer. Denmark also opened an investigation after the Norwegian findings.

Ruter did not say there was any evidence that Yutong had tried to control the buses, and said it would impose “even stricter security requirements in future procurements”. It also said that the buses’ cameras are not connected to the internet, and “there is no risk of image or video transmission from the buses”.

Any evidence that a Chinese manufacturer had interfered with bus or car operations would probably have a devastating impact on vehicle exports, a key industrial aim for China’s government.

Nevertheless, digital security experts have warned for years that over-the-air updates to cars could be a security or privacy threat, either for a hostile state or criminal groups.

Ruter said it had tested two buses from Yutong and Dutch manufacturer VDL in a facility inside a mountain tunnel – a measure that would prevent remote tampering during tests. Yutong’s buses are capable of over-the-air software updates, meaning that the manufacturer has the ability to change software.

Ruter said: “There is access to the control system for battery and power supply via mobile network through a Romanian sim card. In theory, therefore, this bus can be stopped or rendered inoperable by the manufacturer.”

Over-the-air updates are a common feature of modern vehicles, including many mid-range cars made in the UK, US, Europe and China. With slick digital interfaces increasingly becoming one of the most important attractions for buyers, manufacturers and drivers value the ability to access the latest software.

Yutong did not immediately respond to a request for comment. The company previously told the Sunday Times that it “strictly complies with the applicable laws, regulations and industry standards of the locations where its vehicles operate”.

• Carlsbad location is company’s third US-based radioligand therapy (RLT) manufacturing site
• New site expands manufacturing footprint to meet future demand; ensures continued on-time delivery rate of >99.9% to patients across western US, Alaska and Hawaii
• First to have delivered at scale, Novartis fortifies leadership in RLT innovation and infrastructure with California facility, additional plans for Florida and Texas

Basel, November 10, 2025 – Novartis, a leading global innovative medicines company, today announced the opening of a new 10,000-square-foot radioligand therapy (RLT) manufacturing facility in Carlsbad, California. This state-of-the-art site represents a key milestone in the company’s previously announced $23 billion investment in US infrastructure over the next five years.

The opening of the Carlsbad manufacturing facility allows Novartis to seamlessly meet future demand for RLT, adding additional capacity and augmenting the company’s world-class supply chain capabilities. The Carlsbad facility has been filed with the FDA as an additional US point of supply, and commercial manufacturing may begin once approval is granted.

RLTs are a form of precision medicine that combines a tumor-targeting molecule (ligand) with a therapeutic radioisotope, enabling the delivery of radiation to the tumor with the goal of limiting damage to the surrounding cells. Because each RLT dose is custom-made and time-sensitive, with a radioactive half-life measured in hours, proximity to treatment centers and transit hubs helps ensure patients receive their treatment when and where they need it.

“At Novartis, we tackle the toughest challenges in medicine by doing what’s never been done before for patients,” said Vas Narasimhan, CEO of Novartis. “Radioligand therapy is a breakthrough we’ve unlocked at scale, made possible by reimagining how innovation reaches patients. As the global leader in RLT for more than seven years, we’ve advanced this technology with a deep belief in its power to transform cancer care. The opening of our Carlsbad facility underscores our strong commitment to the US and dedication to bringing this pioneering treatment to patients across the country.”

Novartis is the only pharmaceutical company with a dedicated commercial RLT portfolio, and the Carlsbad facility is its third US RLT manufacturing site, reinforcing its global leadership in radioligand therapies with unmatched expertise in development, production, and delivery to patients worldwide. The Carlsbad facility is purpose-built to manufacture the company’s FDA-approved RLTs with capacity for future expansion.

“We commend Novartis for supporting our broader mission of bringing manufacturing capacity in the United States,” said FDA Commissioner Marty Makary, M.D., M.P.H.. “Our unique partnership approach is working.”

“Novartis is transforming the future of cancer care—and it’s happening right here in Carlsbad,” said Carlsbad City Council Member Melanie Burkholder. “This new advanced RLT production facility is a major milestone for our region, strengthening California’s position as a hub for life sciences innovation. It will bring exciting new opportunities for our community, including more engineering and manufacturing jobs. I’m proud our local community will be part of the future of cancer care.”

In addition to the Carlsbad opening, Novartis has announced multiple construction initiatives and future plans in the US, including:

• Two additional RLT manufacturing facilities in Florida and Texas.
• Expansion of existing sites in Durham, North Carolina, Indianapolis, Indiana, and Millburn, New Jersey.
• Establishing its second global R&D hub in the US with a new state-of-the-art biomedical research innovation facility in San Diego, California.

These investments, enabled by a pro-innovation policy and regulatory environment in the US, reflect Novartis’ broad commitment to the market and building its infrastructure. Novartis expects to invest nearly $50 billion in its US operations over the next five years, including the $23 billion announced earlier this year, underscoring its long-term commitment to strengthening the US healthcare ecosystem.

Novartis and Radioligand Therapy (RLT)

Novartis is reimagining cancer care with RLT for patients with advanced cancers. By harnessing the power of targeted radiation and applying it to advanced cancers, RLT is designed to deliver treatment directly to target cells anywhere in the body^3,4.

Novartis is actively investigating the application of RLTs across cancer types and settings, with one of the deepest and most advanced pipelines in the industry, with trials in prostate cancer, breast, colon, lung, brain, pancreatic and other cancers. Novartis has established global expertise, with specialized supply chain and manufacturing capabilities across its network of RLT production sites around the world.

Disclaimer

This press release contains forward-looking statements within the meaning of the United States Private Securities Litigation Reform Act of 1995. Forward-looking statements can generally be identified by words such as “potential,” “can,” “will,” “plan,” “may,” “could,” “would,” “expect,” “anticipate,” “look forward,” “believe,” “committed,” “investigational,” “pipeline,” “launch,” or similar terms, or by express or implied discussions regarding potential marketing approvals, new indications or labeling for the investigational or approved products described in this press release, or regarding potential future revenues from such products. You should not place undue reliance on these statements. Such forward-looking statements are based on our current beliefs and expectations regarding future events, and are subject to significant known and unknown risks and uncertainties. Should one or more of these risks or uncertainties materialize, or should underlying assumptions prove incorrect, actual results may vary materially from those set forth in the forward-looking statements. There can be no guarantee that the investigational or approved products described in this press release will be submitted or approved for sale or for any additional indications or labeling in any market, or at any particular time. Nor can there be any guarantee that such products will be commercially successful in the future. In particular, our expectations regarding such products could be affected by, among other things, the uncertainties inherent in research and development, including clinical trial results and additional analysis of existing clinical data; regulatory actions or delays or government regulation generally; global trends toward health care cost containment, including government, payor and general public pricing and reimbursement pressures and requirements for increased pricing transparency; our ability to obtain or maintain proprietary intellectual property protection; the particular prescribing preferences of physicians and patients; general political, economic and business conditions, including the effects of and efforts to mitigate pandemic diseases; safety, quality, data integrity or manufacturing issues; potential or actual data security and data privacy breaches, or disruptions of our information technology systems, and other risks and factors referred to in Novartis AG’s current Form 20-F on file with the US Securities and Exchange Commission. Novartis is providing the information in this press release as of this date and does not undertake any obligation to update any forward-looking statements contained in this press release as a result of new information, future events or otherwise.

About Novartis
Novartis is an innovative medicines company. Every day, we work to reimagine medicine to improve and extend people’s lives so that patients, healthcare professionals and societies are empowered in the face of serious disease. Our medicines reach nearly 300 million people worldwide.

Reimagine medicine with us: Visit us at https://www.novartis.com and connect with us on LinkedIn, Facebook, X/Twitter and Instagram.

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FORT LAUDERDALE, Fla., Nov. 10, 2025 /PRNewswire/ — Princess Cruises has announced Hampton Water Rosé as the latest addition to the Love Line Premium Liquors Collection. Known for its vibrant flavors and refined craftsmanship, the Hampton Water portfolio will offer Princess guests a still and sparkling rosé for toasting special moments at sea.

Crafted in partnership with Jesse Bongiovi and his dad, Jon Bon Jovi, along with world-renowned winemaker, Gérard Bertrand, Hampton Water Rosé has received critical acclaim for its quality and lively fresh wine. The wines are available fleetwide and included in Princess Premier and Princess Plus  beverage packages.

“Our Love Line Collection celebrates the spirit of connection through premium, celebrity-crafted libations that elevate the onboard experience,” said Sami Kohen, Princess Cruises Vice President of Food and Beverage. “Hampton Water Rosé is more than a wine – it’s a reflection of the lifestyle our guests embrace: vibrant, celebratory, and inspired by the stars they love.”

Princess Cruises Love Line Premium Liquors Collection features a selection of thoughtfully curated wines and spirits, offering both alcohol and non-alcoholic options with a diverse lineup of celebrity-crafted beverages:

• Pantalones Organic Tequila by Camila and Matthew McConaughey
• Meili Vodka by Jason Momoa and Blaine Halvorson
• Sláinte Irish Whiskey by Liev Schreiber
• Archer Roose co-owned by Elizabeth Banks
• Seven Daughters Moscato by Taraji P. Henson
• Melorosa Sauvignon Blanc and Red Blend co-founded by Jason Aldean, Kasi Wicks and Chuck Wicks
• Love Prosecco by Romero Britto
• Zero Alcohol Sparkling Rosé by Kylie Minogue
• Betty Booze by Blake Lively

“Hampton Water is about bringing people together over great conversation and even better wine,” said Jesse Bongiovi. “To have it featured aboard Princess Cruises – a place where countless memories and connections are made – is an incredible opportunity to share our rosé with people who truly value celebration and togetherness.”

The addition of Hampton Water Rosé builds on Princess Cruises’ reputation for delivering exceptional culinary and beverage experiences, ensuring guests have access to innovative and exclusive offerings during their voyage.

For further details about the Love Line Premium Liquors Collection, visit www.princess.com.

Additional information about Princess Cruises is available through a professional travel advisor, by calling 1-800-Princess (1-800-774-6237) or by visiting www.princess.com.

*Princess’ Love Line non-alcohol beverages may contain up to 0.5% alcohol by volume (ABV). These beverages are classified as non-alcoholic under U.S. regulations but may contain trace amounts of alcohol.

About Hampton Water
Jesse and his dad, Jon Bon Jovi, shared a vision to disrupt the wine category with a brand that is unlike all others. The father-son duo created the Hampton Water Wine brand concept, bringing on famed French winemaker, Gérard Bertrand. Launching in 2018 with Hampton Water Rosé, the brand quickly rose above the ranks to be more than just another celebrity brand. It is a family business that has earned four years of 90-point ratings from Wine Spectator, 91 points from Wine Enthusiast and Decanter, and was recognized as an Impact Hot Prospect brand two years in a row. With an incredibly engaged social media presence of over 625,000 followers, Hampton Water is making waves by taking a modern digital approach in an often-traditional category. Seeing such success with the still rosé, Hampton Water is proud to have expanded their brand portfolio with a sparkling rosé in 2024: Hampton Water Bubbly. The brand is creating loyal brand advocates, surpassing their category, and delivering double-digit volume growth year over year.

More information on the company can be found at www.hamptonwaterwine.com, www.facebook.com/hamptonwater, TikTok: @HamptonWater, Instagram: @HamptonWater, and X: @HamptonWater. Sip responsibly.         

About Princess Cruises
Princess Cruises is The Love Boat, the world’s most iconic cruise brand that delivers dream vacations to millions of guests every year in the most sought-after destinations on the largest ships that offer elite service personalization and simplicity customary of small, yacht-class ships. Well-appointed staterooms, world class dining, grand performances, award-winning casinos and entertainment, luxurious spas, imaginative experiences and boundless activities blend with exclusive Princess MedallionClass service to create meaningful connections and unforgettable moments in the most incredible settings in the world – the Caribbean, Alaska, Panama Canal, Mexican Riviera, Europe, South America, Australia/New Zealand, the South Pacific, Hawaii, Asia, Canada/New England, Antarctica, and World Cruises. Sun Princess, the brand’s new, next-level Love Boat named Condé Nast Traveler’s Mega Ship of the Year, introduces the groundbreaking Sphere Class platform and will be joined by sister ship, Star Princess, in Fall 2025. The company is part of Carnival Corporation & plc (NYSE/LSE:CCL; NYSE:CUK). 

SOURCE Princess Cruises