Nonspecific Orbital Inflammation (NSOI): Unraveling the Molecular Pathogenesis, Diagnostic Modalities, and Therapeutic Interventions

Nonspecific orbital inflammation (NSOI), colloquially known as orbital pseudotumor, sometimes presents a diagnostic and therapeutic challenge in ophthalmology. This review aims to dissect NSOI through a molecular lens, offering a comprehensive overview of its pathogenesis, clinical presentation, diagnostic methods, and management strategies. The article delves into the underpinnings of NSOI, examining immunological and environmental factors alongside intricate molecular mechanisms involving signaling pathways, cytokines, and mediators. Special emphasis is placed on emerging molecular discoveries and approaches, highlighting the significance of understanding molecular mechanisms in NSOI for the development of novel diagnostic and therapeutic tools. Various diagnostic modalities are scrutinized for their utility and limitations. Therapeutic interventions encompass medical treatments with corticosteroids and immunomodulatory agents, all discussed in light of current molecular understanding. More importantly, this review offers a novel molecular perspective on NSOI, dissecting its pathogenesis and management with an emphasis on the latest molecular discoveries. It introduces an integrated approach combining advanced molecular diagnostics with current clinical assessments and explores emerging targeted therapies. By synthesizing these facets, the review aims to inform clinicians and researchers alike, paving the way for molecularly informed, precision-based strategies for managing NSOI.

Performance of ChatGPT on Ophthalmology-Related Questions Across Various Examination Levels: Observational Study

BACKGROUND

ChatGPT and language learning models have gained attention recently for their ability to answer questions on various examinations across various disciplines. The question of whether ChatGPT could be used to aid in medical education is yet to be answered, particularly in the field of ophthalmology.

OBJECTIVE

The aim of this study is to assess the ability of ChatGPT-3.5 (GPT-3.5) and ChatGPT-4.0 (GPT-4.0) to answer ophthalmology-related questions across different levels of ophthalmology training.

METHODS

Questions from the United States Medical Licensing Examination (USMLE) steps 1 (n=44), 2 (n=60), and 3 (n=28) were extracted from AMBOSS, and 248 questions (64 easy, 122 medium, and 62 difficult questions) were extracted from the book, Ophthalmology Board Review Q&A, for the Ophthalmic Knowledge Assessment Program and the Board of Ophthalmology (OB) Written Qualifying Examination (WQE). Questions were prompted identically and inputted to GPT-3.5 and GPT-4.0.

RESULTS

GPT-3.5 achieved a total of 55% (n=210) of correct answers, while GPT-4.0 achieved a total of 70% (n=270) of correct answers. GPT-3.5 answered 75% (n=33) of questions correctly in USMLE step 1, 73.33% (n=44) in USMLE step 2, 60.71% (n=17) in USMLE step 3, and 46.77% (n=116) in the OB-WQE. GPT-4.0 answered 70.45% (n=31) of questions correctly in USMLE step 1, 90.32% (n=56) in USMLE step 2, 96.43% (n=27) in USMLE step 3, and 62.90% (n=156) in the OB-WQE. GPT-3.5 performed poorer as examination levels advanced (P<.001), while GPT-4.0 performed better on USMLE steps 2 and 3 and worse on USMLE step 1 and the OB-WQE (P<.001). The coefficient of correlation (r) between ChatGPT answering correctly and human users answering correctly was 0.21 (P=.01) for GPT-3.5 as compared to -0.31 (P<.001) for GPT-4.0. GPT-3.5 performed similarly across difficulty levels, while GPT-4.0 performed more poorly with an increase in the difficulty level. Both GPT models performed significantly better on certain topics than on others.

CONCLUSIONS

ChatGPT is far from being considered a part of mainstream medical education. Future models with higher accuracy are needed for the platform to be effective in medical education.

Beyond Vision: An Overview of Regenerative Medicine and Its Current Applications in Ophthalmological Care

Regenerative medicine (RM) has emerged as a promising and revolutionary solution to address a range of unmet needs in healthcare, including ophthalmology. Moreover, RM takes advantage of the body's innate ability to repair and replace pathologically affected tissues. On the other hand, despite its immense promise, RM faces challenges such as ethical concerns, host-related immune responses, and the need for additional scientific validation, among others. The primary aim of this review is to present a high-level overview of current strategies in the domain of RM (cell therapy, exosomes, scaffolds, in vivo reprogramming, organoids, and interspecies chimerism), centering around the field of ophthalmology. A search conducted on clinicaltrials.gov unveiled a total of at least 209 interventional trials related to RM within the ophthalmological field. Among these trials, there were numerous early-phase studies, including phase I, I/II, II, II/III, and III trials. Many of these studies demonstrate potential in addressing previously challenging and degenerative eye conditions, spanning from posterior segment pathologies like Age-related Macular Degeneration and Retinitis Pigmentosa to anterior structure diseases such as Dry Eye Disease and Limbal Stem Cell Deficiency. Notably, these therapeutic approaches offer tailored solutions specific to the underlying causes of each pathology, thus allowing for the hopeful possibility of bringing forth a treatment for ocular diseases that previously seemed incurable and significantly enhancing patients' quality of life. As advancements in research and technology continue to unfold, future objectives should focus on ensuring the safety and prolonged viability of transplanted cells, devising efficient delivery techniques, etc.

Surgical approach for management of complete anterior capsular contraction syndrome

Anterior capsular contraction syndrome is an uncommon but well-known complication associated with continuous curvilinear capsulorhexis performed during cataract surgery. It remains asymptomatic unless the constriction progresses to involve the visual axis or causes late intraocular lens-related complications. A male patient in his 50s presented with severely decreased vision in his right eye 2 years after uneventful cataract surgery. Slit-lamp biomicroscopy revealed capsular phimosis and a dense, central, fibrous plaque with total occlusion of the anterior capsulorhexis opening. Neodymium-doped yttrium aluminium garnet laser anterior capsulotomy and vitrectorhexis were attempted, but proved ineffective. Surgical excision with manual cutting of the fibrotic membrane was performed, successfully clearing the visual axis and restoring vision.

Deep learning-based identification of eyes at risk for glaucoma surgery

To develop and evaluate the performance of a deep learning model (DLM) that predicts eyes at high risk of surgical intervention for uncontrolled glaucoma based on multimodal data from an initial ophthalmology visit. Longitudinal, observational, retrospective study. 4898 unique eyes from 4038 adult glaucoma or glaucoma-suspect patients who underwent surgery for uncontrolled glaucoma (trabeculectomy, tube shunt, xen, or diode surgery) between 2013 and 2021, or did not undergo glaucoma surgery but had 3 or more ophthalmology visits. We constructed a DLM to predict the occurrence of glaucoma surgery within various time horizons from a baseline visit. Model inputs included spatially oriented visual field (VF) and optical coherence tomography (OCT) data as well as clinical and demographic features. Separate DLMs with the same architecture were trained to predict the occurrence of surgery within 3 months, within 3-6 months, within 6 months-1 year, within 1-2 years, within 2-3 years, within 3-4 years, and within 4-5 years from the baseline visit. Included eyes were randomly split into 60%, 20%, and 20% for training, validation, and testing. DLM performance was measured using area under the receiver operating characteristic curve (AUC) and precision-recall curve (PRC). Shapley additive explanations (SHAP) were utilized to assess the importance of different features. Model prediction of surgery for uncontrolled glaucoma within 3 months had the best AUC of 0.92 (95% CI 0.88, 0.96). DLMs achieved clinically useful AUC values (> 0.8) for all models that predicted the occurrence of surgery within 3 years. According to SHAP analysis, all 7 models placed intraocular pressure (IOP) within the five most important features in predicting the occurrence of glaucoma surgery. Mean deviation (MD) and average retinal nerve fiber layer (RNFL) thickness were listed among the top 5 most important features by 6 of the 7 models. DLMs can successfully identify eyes requiring surgery for uncontrolled glaucoma within specific time horizons. Predictive performance decreases as the time horizon for forecasting surgery increases. Implementing prediction models in a clinical setting may help identify patients that should be referred to a glaucoma specialist for surgical evaluation.

Predicting Implantable Collamer Lens Vault Using Machine Learning Based on Various Preoperative Biometric Factors

Purpose

To predict the vault size after Implantable Collamer Lens (ICL) V4c implantation using machine learning methods and to compare the predicted vault with the conventional manufacturer's nomogram.

Methods

This study included 707 patients (707 eyes) who underwent ICL V4c implantation at the Department of Ophthalmology, Peking Union Medical College Hospital, from September 2019 to January 2022. Random Forest Regression (RFR), XGBoost, and linear regression (LR) were used to predict the vault size 1 week after ICL V4c implantation. The mean absolute error (MAE), median absolute error (MedAE), root mean square error (RMSE), symmetric mean absolute percentage error (SMAPE), and Bland-Altman plot were utilized to compare the prediction performance of these machine learning methods.

Results

The dataset was divided into a training set of 180 patients (180 eyes) and a test set of 527 patients (527 eyes). XGBoost had the lowest prediction error, with mean MAE, RMSE, and SMAPE values of 121.70 µm, 148.87 µm, and 19.13%, respectively. The Bland‒Altman plots of RFR and XGBoost showed better prediction consistency than LR. However, XGBoost showed narrower 95% limits of agreement (LoA) than RFR, ranging from -307.12 to 256.59 µm.

Conclusions

XGBoost demonstrated better predictive performance than RFR and LR, as it had the lowest prediction error and the narrowest 95% LoA. Machine learning may be applicable for vault prediction, and it might be helpful for reducing the complications and the secondary surgery rate.

Translational Relevance

Using the proposed machine learning model, surgeons can consider the postoperative vault to reduce the surgical complications.

Leadership in ophthalmology by humanity and competence

Leadership in healthcare institutions has a direct impact on the practice of the medical and nursing professions. The respective leadership style that is cultivated in a medical institution therefore has a direct impact on the personnel and thus a direct impact on the treatment of patients, in both senses of the word. Leadership in healthcare should therefore inspire, motivate, and guide healthcare workers to use their individual and collective skills as well as the available resources in the best possible way for the benefit of patients. This is the task and obligation of all those working in the healthcare system. The German Society of Ophthalmology (DOG) has established a leadership academy for ophthalmologists to meet the requirements of the modern healthcare market for leadership qualifications.

Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

Tracing the barriers to decarbonising ophthalmology: A review

As climate change demands increasingly urgent mitigation of greenhouse gas emissions, the health sector needs to do its part to decarbonise. Ophthalmologists share concerns about climate change and seek opportunities to reduce their environmental impact. When measuring the footprint of ophthalmology, major contributions are from patient travel to clinics, and from the large amounts of single-use disposable materials that are consumed during surgeries and sterile procedures. Ophthalmic services in India have already demonstrated systems that consume far fewer of these products through efficient throughput of patients and the safe reuse of many items, while maintaining equivalent safety and quality outcomes. Choosing these low-cost low-emission options would seem obvious, but many ophthalmologists experience barriers that prevent them operating as Indian surgeons do. Understanding these barriers to change is a crucial step in the decarbonisation of ophthalmology and the health sector more broadly.

The 200-Year Timeline on Botulinum Toxin: From Biologic Poison to Wonder Drug

The history of botulinum toxin dates back to the late 1700s, when food preparation, storage, and later canning practices led to outbreaks of botulism across Europe and the United States. It is from these initial incidents that the remarkable discovery of botulinum toxin was eventually made, sparking over 200 years of further scientific inquiry and medical innovation. To date, 6 botulinum toxin products have been commercialized in North America with numerous indications across the specialties of ophthalmology, neurology, urology, dermatology, plastic surgery, and otolaryngology. This article traces the key moments and important players in the remarkable journey of this biologic poison and wonder drug. J Drugs Dermatol. 2024;23(1) doi:10.36849/JDD.7288.

Post Stroke Visual Impairment: Interdisciplinary Collaborative Program - Canadian Perspective

Post-stroke visual impairment (PSVI) affects more than 60% of the people who have a stroke but visual function is not routinely assessed in most stroke units. Recent high-quality research in this field has produced evidence-based assessment and management practices for PSVI. Orthoptists have integrated into the stroke care team in the United Kingdom (UK) to provide this valuable service. This paper outlines the development and implementation of the first known orthoptic PSVI service in North America. A pilot program was developed between the Ophthalmology, Neurology, and Physical Medicine and Rehabilitation Departments in Saskatoon, Saskatchewan, Canada. A new referral pathway was established to refer stroke patients with PSVI directly to an orthoptist with specialization in PSVI. Clinical findings from the first year of operation are reported. One hundred and seven visual deficits were suspected by the referring service. Visual field deficits were the most commonly reported PSVI. Diplopia was the most commonly reported oculomotor deficit in this cohort, and visual neglect/inattention was the most common visual perceptual deficit reported. Reading issues were the most commonly reported functional issues. Following assessment by an orthoptist, 45 additional visual deficits were identified and addressed. Stroke patients require assessment and treatment for PSVI. Orthoptists are perfectly suited to PSVI assessment and management. There is an opportunity to increase orthoptists' scope of practice in North America to ensure stroke patients receive specialized vision assessment and treatment.

Effect of pre-admission "quasi-collective" education on health education for patients with ophthalmic day surgery

BACKGROUND

Day surgery is a new surgical model in which patients complete the admission, surgery, and discharge on the same day.

OBJECTIVE

The present study aimed to explore the effect of pre-admission "quasi-collective" health education for patients with ophthalmic day surgery.

METHODS

For this study, a total of 200 patients undergoing ophthalmic day surgery from February 2019 to December 2019 were enrolled as the research subjects. The patients were divided randomly into the observation group and the control group, with 100 cases in each group. For the control group, conventional health education was conducted after admission. On the day of admission, the admission education and peri-operative health education were performed. For the observation group, pre-admission health education was provided to the patients, and detailed education on the admission instructions, pre-operative precautions, and simulation of the intra-operative process were given by the medical staff. On the day of admission, the understanding of the education was evaluated, and any weaknesses in the health education were addressed. The anxiety status, method of handwashing, method of administering the drug to the eye, preoperative preparations, intra-operative training, preoperative medication, diet guidance, and postoperative care were compared between the two groups of patients.

RESULTS

Before discharge, there were significant differences in the anxiety scores, impact, and satisfaction of health education between the two groups of patients, all of which were statistically significant (P< 0.05).

CONCLUSION

The pre-admission "quasi-collective" health education for patients undergoing day surgery in ophthalmology was better than conventional health education.

Insights into artificial intelligence in myopia management: from a data perspective

Given the high incidence and prevalence of myopia, the current healthcare system is struggling to handle the task of myopia management, which is worsened by home quarantine during the ongoing COVID-19 pandemic. The utilization of artificial intelligence (AI) in ophthalmology is thriving, yet not enough in myopia. AI can serve as a solution for the myopia pandemic, with application potential in early identification, risk stratification, progression prediction, and timely intervention. The datasets used for developing AI models are the foundation and determine the upper limit of performance. Data generated from clinical practice in managing myopia can be categorized into clinical data and imaging data, and different AI methods can be used for analysis. In this review, we comprehensively review the current application status of AI in myopia with an emphasis on data modalities used for developing AI models. We propose that establishing large public datasets with high quality, enhancing the model's capability of handling multimodal input, and exploring novel data modalities could be of great significance for the further application of AI for myopia.

Analysis of 50 Most Cited Articles About Refractive Surgery From an Altmetric Perspective

AIMS

The purpose of this study is to evaluate an Altmetric analysis of the 50 most cited refractive surgery articles in Ophthalmology journals and to compare them with traditional metrics.

METHODS

The term "refractive surgery" was searched, using a time filter between 2010-2020 in the Web of Science core collection database. The 50 most cited articles between 2010 and 2020 were recorded. Descriptive statistics were performed. The Spearman correlation test was used to evaluate the correlation between traditional metrics and Altmetrics.

RESULTS

The Altmetric scores of the top 50 articles ranged from 0 to 25, and the median Altmetric score was 4. The citation numbers of the 50 articles ranged from 83 to 523, and the median citation number was 119.5. The most cited article topic was "Toric Intraocular Lens"; the topics with the highest Altmetric scores were "Toric Intraocular Lens" and "Trifocal Intraocular Lens". There was no significant correlation between Altmetric scores and number of citations. There was a weak correlation between Altmetric scores and the average citation per year.

CONCLUSION

The Altmetric score is insufficient, compared with traditional metrics, to show the scientific value of articles on refractive surgery. Altmetrics can be used to supplement traditional metrics.

Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology

PURPOSE

To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, "Laser Trabeculoplasty for Open-Angle Glaucoma," published in November 2011.

METHODS

Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies.

RESULTS

Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT.

CONCLUSIONS

Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

[ARTIFICIAL INTELLIGENCE IN OPHTHALMOLOGY]

INTRODUCTION

Artificial intelligence (AI) was first introduced in 1956, and effectively represents the fourth industrial revolution in human history. Over time, this medium has evolved to be the preferred method of medical imagery interpretation. Today, the implementation of AI in the medical field as a whole, and the ophthalmological field in particular, is diverse and includes diagnose, follow-up and monitoring of the progression of ocular diseases. For example, AI algorithms can identify ectasia, and pre-clinical signs of keratoconus, using images and information computed from various corneal maps. Machine learning (ML) is a specific technique for implementing AI. It is defined as a series of automated methods that identify patterns and templates in data and leverage these to perform predictions on new data. This technology was first applied in the 1980s. Deep learning is an advanced form of ML inspired by and designed to imitate the human brain process, constructed of layers, each responsible for identifying patterns, thereby successfully modeling complex scenarios. The significant advantage of ML in medicine is in its' ability to monitor and follow patients with efficiency at a low cost. Deep learning is utilized to monitor ocular diseases such as diabetic retinopathy, age-related macular degeneration, glaucoma, cataract, and retinopathy of prematurity. These conditions, as well as others, require frequent follow-up in order to track changes over time. Though computer technology is important for identifying and grading various ocular diseases, it still necessitates additional clinical validation and does not entirely replace human diagnostic skill.

Interspecialty Opioid Prescribing Patterns in Ophthalmology Following Declaration of a Public Health Emergency

Purpose: Previous literature has investigated opioid prescription trends in ophthalmology at large, however, little has been done looking at differences between subspecialties. We evaluate if significant trends exist among subspecialties in opioid prescribing patterns. This study aims to illuminate potential over-usage of opioids in ophthalmology that could compromise patient quality of life. Methods: Medicare data and "National Plan and Provider Enumeration System (NPPES) Downloadable File" were queried for cases of ophthalmologists with nonsuppressed opioid prescription data from 2014 to 2019. Ophthalmologists with no subspecialty code or missing regional, gender, degree, or graduation information were excluded. Chi-squared analysis, analysis of variance, t-tests, and multivariate logistic regression were utilized. Results: Five thousand one hundred forty-three physician records were included in analysis, 450 of which were by cornea subspecialists. Most cornea cases were male, graduated before 2005, and practiced in the South. All subspecialties had a significantly increased likelihood of making opioid claims and higher prescription rates compared with cornea (P < 0.050) besides glaucoma (P = 0.357). Only oculoplastics had significantly increased likelihood of greater total supply of opioids compared with cornea (odds ratio [OR] = 22.195, 95% confidence interval [CI] = 12.209-40.350, P < 0.001), while pediatrics (OR = 4.036, 95% CI = 1.377-11.831, P = 0.011) and neuro-ophthalmology (OR = 4.158, 95% CI = 1.237-13.975, P = 0.021) in addition to oculoplastics (OR = 64.380, 95% CI = 26.306-157.560, P < 0.001) were predicted to have significantly greater opioid beneficiaries. Males, the South/Midwest, and graduating before 2005, all were generally associated with increased likelihood of greater total opioid claims, supply, beneficiaries, and prescription rate (P < 0.050). Conclusion: Subspecialty, demographic, chronological, and regional trends exist for opioid prescribing patterns in ophthalmology.

Rho Kinase (ROCK) Inhibitors for the Treatment of Glaucoma

Glaucoma is the most common cause of irreversible blindness worldwide. It is characterized by progressive optic nerve degeneration and loss of visual field. Pathological increased intraocular pressure is its main modifiable risk factor. Rho kinase inhibitors are developed as a new class of glaucoma medication that increases outflow facility from the conventional aqueous humor outflow pathway. Additionally, they also have neuroprotective and anti-scarring effects that can might increase the success rate of glaucoma filtration surgery. This review aims to summarize the current concept of Rho kinase inhibitors in the treatment of glaucoma from beach to bedside.

Advanced Corneal Imaging in Keratoconus: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the diagnostic capabilities of the newest generation of corneal imaging devices for the identification of keratoconus.

METHODS

Corneal imaging devices studied included tomographic platforms (Scheimpflug photography, OCT) and functional biomechanical devices (imaging an air impulse on the cornea). A literature search in the PubMed database for English language studies was last conducted in February 2023. The search yielded 469 citations, which were reviewed in abstract form. Of these, 147 were relevant to the assessment objectives and underwent full-text review. Forty-five articles met the criteria for inclusion and were assigned a level of evidence rating by the panel methodologist. Twenty-six articles were rated level II, and 19 articles were rated level III. There were no level I evidence studies of corneal imaging for the diagnosis of keratoconus found in the literature. To provide a common cross-study outcome measure, diagnostic sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were extracted. (A perfect diagnostic test that identifies all cases properly has an AUC of 1.0.) RESULTS: For the detection of keratoconus, sensitivities for all devices and parameters (e.g., anterior or posterior corneal curvature, corneal thickness) ranged from 65% to 100%. The majority of studies and parameters had sensitivities greater than 90%. The AUCs ranged from 0.82 to 1.00, with the majority greater than 0.90. Combined indices that integrated multiple parameters had an AUC in the mid-0.90 range. Keratoconus suspect detection performance was lower with AUCs ranging from 0.66 to 0.99, but most devices and parameters had sensitivities less than 90%.

CONCLUSIONS

Modern corneal imaging devices provide improved characterization of the cornea and are accurate in detecting keratoconus with high AUCs ranging from 0.82 to 1.00. The detection of keratoconus suspects is less accurate with AUCs ranging from 0.66 to 0.99. Parameters based on single anatomic locations had a wide range of AUCs. Studies with combined indices using more data and parameters consistently reported high AUCs.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Retinal changes after fluocinolone acetonide implant (ILUVIEN®) for DME: SD-OCT imaging assessment using ESASO classification

INTRODUCTION

A detailed understanding of the anatomical and structural changes occurring in the retina following intravitreal fluocinolone acetonide implantation may help improve the management and prognosis of persistent or recurrent diabetic macular edema (DME).

METHODS

Overall, 45 eyes (from 35 patients) with refractory center-involved DME received an intravitreal fluocinolone acetonide implant. They were monitored at baseline and at 6, 12, 24, and 36 months for best-corrected visual acuity (BCVA), central foveal thickness (CFT), and the seven retinal parameters used in the classification of diabetic maculopathy recently developed at the European School for Advanced Studies in Ophthalmology (ESASO).

RESULTS

Within 6 months of implantation, significant improvements were evident in BCVA, CFT, maculopathy stage, and the percentage of eyes with: intraretinal cysts; CFT > 30% above the upper normal value; and disrupted or absent ellipsoid zone (EZ) and/or external limiting membrane (ELM). Significant improvements were still maintained at 36 months post-implantation. At month 36, early treatment with the implant (i.e., after < 6 previous intravitreal injections for DME) trended toward being more effective than later treatment in improving BCVA, CFT, maculopathy stage, and the percentage of eyes with CFT > 30% above the upper normal value. However, statistical significance was not achieved.

CONCLUSION

In persistent or recurrent DME, fluocinolone acetonide implantation can be effective in improving maculopathy stage and reducing the percentage of eyes with: intraretinal cysts; CFT > 30% above the upper normal value; and disrupted or absent EZ and/or ELM. It can also increase BCVA and reduce CFT.

[Diagnosis of combined ophthalmic and dermatological manifestations of HIV]

This article contains up-to-date information on the features of ophthalmological and dermatological manifestations of human immunodeficiency virus (HIV) infection based on the analysis of studies published in 2018-2022. The article also presents a description of a clinical case of HIV infection in a 54-year-old female patient with synchronous manifestation of eye symptoms in the form of retinal vasculitis of the optic nerve head and Kaposi's sarcoma localized on the skin of the face.

Scleral Grafts in Ophthalmic Surgery. A Review

AIM

To summarize the history and current trends in the use of scleral grafts in ophthalmology.

MATERIALS AND METHODS

We conducted a review of the literature through the MEDLINE and Cochrane Library databases. The search terms were "sclera", "graft", and "surgery". The search resulted in 1596 articles, of which we evaluated 192 as relevant. The relevant articles were sorted chronologically and according to the method of using scleral grafts, which enabled the development of a review article.

RESULTS

The sclera has been routinely used in ophthalmology since the 1950s in many different indications. Some of these indications have become practically obsolete over time (for example, use in the surgical management of retinal detachment), but a large number still find application today (especially use in glaucoma or oculoplastic surgery, or as a patch for a defect in the sclera or cornea).

CONCLUSION

Even though allogeneic sclera is currently used less frequently in ophthalmology compared to other tissue banking products and the range of its indications has partially narrowed, it remains a useful material due to its availability and properties.

[The first experience of using femtosecond laser in the treatment of anterior capsular contraction syndrome]

Prevention and treatment of anterior capsular contraction syndrome (ACCS) is a relevant problem in cataract surgery.

PURPOSE

The study was performed to develop a femtosecond laser-assisted technique for anterior capsulotomy in anterior capsular contraction syndrome and assess its preliminary results in preventing the progression of pathological changes in the capsular bag.

MATERIAL AND METHODS

The examination and femtosecond laser-assisted treatment without additional surgical intervention was performed in 6 patients (6 eyes) aged 69 to 73 years with anterior capsular contraction syndrome. Femtosecond laser-assisted anterior capsulotomy was performed using the VICTUS system (Technolas Perfect Vision, Germany). Capsulotomy diameter was 4.0-4.5 mm, laser radiation energy - 9000 nJ, laser exposure depth 900-1000 μm.

RESULTS

The diameter of the anterior capsulotomy before treatment was 2.85 mm [2.75; 2.93]. After 1 month, the diameter of the anterior capsular opening was 2.88 mm [2.78; 2.96] (p>0.05). One year after femtosecond laser intervention, the anterior capsulotomy opening was almost the same shape and diameter - 2.84 mm [2.74; 2.94] (p>0.05).

CONCLUSION

Femtosecond laser-assisted circular capsulotomy is an effective and safe method for preventing the progression of anterior capsular contraction syndrome in the absence of severe IOL decentration and for maintaining the diameter of the anterior capsular opening of at least 2.5-3.0 mm.

An overview of neuro-ophthalmic disorders at Jenna Ophthalmic Center, Baghdad, Iraq (2021-2022)

Neuro-ophthalmic disorders are often documented individually for each illness, with little data available on their overall incidence and pattern. The overall incidence of neuro-ophthalmic illnesses in Iraq is still not recorded. This study aimed to evaluate the clinical, demographic, and etiological features of patients seeking consultation at an Iraqi neuro-ophthalmology clinic. A prospective cross-sectional observational research was conducted at the Janna Ophthalmic Center in Baghdad, Iraq. The center serves a diverse patient population from various governorates. All newly diagnosed patients with neuro-ophthalmic disorders who visited the neuro-ophthalmological clinic, regardless of gender or age group, were included. The neuro-ophthalmologist established a diagnosis for each case by reviewing the patient's medical history, doing physical examinations, administering specific tests, and, in certain cases, using neuroimaging methods. The duration of the study was extended from March 2021 to November 2022. Among the 6440 patients evaluated, 613 cases were confirmed at the neuro-ophthalmology clinic. Ischemic optic neuropathy (NAION, AION, and PION) was the most prevalent diagnosis, accounting for 17.61% of newly reported cases in the field of neuro-ophthalmology. This was followed by sixth nerve palsy. Diabetes mellitus affected 42.7% of the cases, followed by hypertension, which affected 39.3% of the participants. The incidence of neuro-ophthalmic diseases tended to be high. Ischemic optic neuropathy and sixth nerve palsy, traumatic/compressive optic neuropathy, and papilledema were the most common neuro-ophthalmic disorders reported.

Sexually transmitted infections and HIV in ophthalmology

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Reliability of Intraocular Pressure Measurements in a Low-Contact Drive-Through Setting

PRCIS

Drive-through intraocular pressure (IOP) measurement using iCare tonometry is a promising method of low-contact, high-throughput IOP monitoring. However, owing to its vulnerability to variable measurement technique and local air currents, the iCare may overestimate IOPs.

PURPOSE

During the COVID-19 pandemic, a drive-through IOP measurement protocol using the iCare tonometer was established to facilitate low-contact monitoring of select glaucoma patients. As the iCare may be prone to error due to variable measurement technique and local air currents, we endeavored to assess the reliability of drive-through IOP measurements by comparing them with recent measurements taken in clinic settings.

METHODS

Inclusion criteria were patients with drive-through IOP measurements performed from April 28 to October 11, 2020; exclusion criteria were pre-drive-through IOPs >21 mmHg. Drive-through IOP measurements were compared with the closest previous and/or subsequent in-clinic IOP measurements. Data were gathered using the Sight Outcomes Research Collaborative (SOURCE) data repository.

RESULTS

The post-exclusion study group consisted of 314 patients receiving a total of 868 drive-through IOP measurements, all of whom had prior in-clinic measurements, and 56.8% of whom had subsequent in-clinic measurements. Drive-through IOPs were, on average, +2.4 mmHg (+14.5%; SD 4.9) higher than in-clinic IOPs. Further sub-analysis of the data showed a difference of +2.1 mmHg OD and +2.6 mmHg OS. Compared with the closest previous in-clinic visit, the difference was +2.4 mmHg OU (+2.1 mmHg OD, +2.7 mmHg OS); compared with the closest subsequent in-clinic visit, the difference was +2.3 mmHg OU (+2.1 mmHg OD, +2.5 mmHg OS). 68.6% of all drive-through IOPs were higher than corresponding in-clinic IOPs; 21.1% were lower. 25.9% of drive-through IOPs were higher by more than 5 mmHg, whereas 3.9% of drive-through IOPs were lower by more than 5 mmHg.

DISCUSSION

As teleophthalmology becomes an ever more important tool in glaucoma patient care, drive-through or walk-through IOP monitoring methods are likely to play an increasing role. However, our data reveals potential inaccuracies in drive-through iCare IOP measurements which tended to overestimate IOP. It is advisable to confirm large changes in IOP with in-clinic measurement before making management decisions.

CONCLUSION

With better optimization of accuracy and reliability of measurements, drive-through tonometry is a promising, high-throughput, low-contact method of measuring IOP.

Reimagining the Past: A Future for Antibiotic Drug Discovery in Ophthalmology

ABSTRACT

Antibiotic resistance has emerged as a critical threat for the treatment of bacterial ocular infections. To address the critical need for novel therapeutics, antibiotic drug repurposing holds significant promise. As such, examples of existing FDA-approved drugs currently under development for new applications, novel combinations, and improved delivery systems are discussed.

Overlap between ophthalmology and psychiatry - A narrative review focused on congenital and inherited conditions

A number of congenital and inherited diseases present with both ocular and psychiatric features. The genetic inheritance and phenotypic variants play a key role in disease severity. Early recognition of the signs and symptoms of those disorders is critical to earlier intervention and improved prognosis. Typically, the associations between these two medical subspecialties of ophthalmology and psychiatry are poorly understood by most practitioners so we hope to provide a narrative review to improve the identification and management of these disorders. We conducted a comprehensive review of the literature detailing the diseases with ophthalmic and psychiatric overlap that were more widely represented in the literature. Herein, we describe the clinical features, pathophysiology, molecular biology, diagnostic tests, and the most recent approaches for the treatment of these diseases. Recent studies have combined technologies for ocular and brain imaging such as optical coherence tomography (OCT) and functional imaging with genetic testing to identify the genetic basis for eye-brain connections. Additional work is needed to further explore these potential biomarkers. Overall, accurate, efficient, widely distributed and non-invasive tests that can help with early recognition of these diseases will improve the management of these patients using a multidisciplinary approach.

A history of visual acuity testing and optotypes

After going into the etymology of the word "optotype", this article covers some tasks in ancient times that required good visual acuity (VA). Around 300 BCE, Euclid formulated the existence of a visual cone with a minimal visual angle at its tip. Trials to test VA appeared AD 1754. Around that time, texts were introduced by opticians in order to be able to prescribe more reliably. In the early nineteenth century, the need for VA tests in ophthalmology resulted in German and English test charts. Numerous variants emerged after the first edition of Snellen's optotypes in 1862 in The Netherlands. However, 100 years later there was still no standard optotype to reliably test VA. Multidisciplinary approaches between ophthalmology, linguistics, psychology and psychophysics improved optotypes and VA testing, which led to the more reliable LogMAR charts. Recent advances in aids and therapies for the blind and severely visually handicapped, necessitate further development of new and standardized VA tests.

Female Representation in Pediatric Ophthalmology at the American Academy of Ophthalmology Annual Meeting From 2018 to 2022

PURPOSE

To identify trends in female pediatric ophthalmologist authorship and representation at the American Academy of Ophthalmology (AAO) Annual Meeting from 2018 to 2022.

METHODS

Participant data from 2018 to 2022 were collected from the AAO website, organized by conference activity (papers, posters, instruction courses, videos, symposia, subspecialty day, and awards), and analyzed by sex using an online tool. Chi-squared and odds ratio analyses were performed to determine trends in authorship sex and associations between the sex of paper and poster authors in each category.

RESULTS

Of 923 pediatric ophthalmology presentations from 2018 to 2022, 46.2% (426 of 923) of presenters and 46.6% (281 of 603) of unique individual participants were women. Overall, 48% (174 of 362) of first and senior authors of papers and posters were women. No significant difference or association between female first and senior authors was observed (52% vs 44%, P = .14; odds ratio 1.59, P = .13). There was no significant change in the proportion of total female presenters from 2018 to 2019 (-3.09%, P = .53), 2019 to 2020 (0.76%, P = .88), 2020 to 2021 (9.09%, P = .09), 2021 to 2022 (-5.68%, P = .30), or 2018 to 2022 (1.08%, P = .84).

CONCLUSIONS

Since 2018, female representation at the AAO Annual Meeting has remained consistent and nears 50%. The lack of a significant difference between the proportion of female first and senior authors suggests that junior female pediatric ophthalmologists are climbing the ranks and more broadly engaging in mentorship roles. Considering the increasing proportion of female pediatric ophthalmologists, the absence of corollary, statistically significant increases in female participation may be of concern. [J Pediatr Ophthalmol Strabismus. 2024;61(1):6-13.].

Improved Clinic Flow and Satisfaction After Lean Implementation in a Pediatric Ophthalmology Clinic

PURPOSE

To report outcomes using Lean concepts (FlowOne Lean Consulting, LLC) and implemented changes in a single academic pediatric ophthalmology practice.

METHODS

Lean principles such as patient flow, wasted movement, and non-value added visit time were taught to clinic staff. Spaghetti maps to document patient and staff movement during examinations, patient simulation, and clinic flow exercises were performed prior to implementing clinic changes. Clinic changes included maximizing easily reachable equipment and standardizing equipment in each examination room, physician-controlled doorbells to notify staff for help, and implementing a visual real-time electronic board of patients throughout the entirety of their examination. Patient surveys before and after Lean and staff feedback were obtained.

RESULTS

Four years of data were collected of patient examination visits after Lean principles were introduced. Prior to Lean implementation, mean pediatric ophthalmology clinic visit times were 120 minutes. Within 3 months of Lean clinic changes, mean visit times reduced to 75 minutes. Four years later, this was sustained at 69 minutes. Clinic templates were modified and increased by 17%. Patient satisfaction surveys before and after demonstrated improved scores from 6.5 to 9.0. Patient survey comments included satisfaction with shorter patient examination visits, less shuffling between examination rooms, less non-value added time, and perception of happier clinic staff. Staff survey comments included receiving fewer parent complaints, feeling less disorganized, being able to troubleshoot in real time, and leaving at an earlier time at the end of the clinic day.

CONCLUSIONS

Lean improved clinic efficiency, reduced patient visit times, and improved patient and staff satisfaction. These improvements were sustained 4 years after Lean principles were implemented. [J Pediatr Ophthalmol Strabismus. 2024;61(1):14-19.].

Glaucoma Surgery Shifts Among Medicare Beneficiaries After 2022 Reimbursement Changes in the United States

PRCIS

This study revealed the best-estimated surgical procedural counts for 2021 and 2022 and suggests a direct influence of coding and reimbursement changes on surgical device selection.

PURPOSE

To analyze utilization rates of glaucoma surgeries and minimally invasive (microinvasive) glaucoma surgery among US Medicare beneficiaries between 2021 and 2022.

DESIGN

Retrospective comparative analysis of 68,118 unique patients.

METHODS

National claims data from a 5% sample of all Medicare beneficiaries were utilized to compare glaucoma procedure counts between the first quarter of 2021 and the first quarter of 2022. Duplicate claims were excluded, and 50 modifiers were counted as 2 distinct procedures. A multiplier was applied to estimate annual utilization for the entire Medicare population. χ 2 analysis was employed to compare categorical data from the 2 time periods.

RESULTS

Current Procedural Terminology codes for angle-based stenting decreased by an estimated 20,960 procedures between 2021 and 2022 (28.60%). Goniotomy increased by an estimated 11,680 procedures (66.97%) and canaloplasty increased by an estimated 6640 procedures (47.43%). Glaucoma surgeries decreased by an estimated 5760 procedures (4.25%) despite an increase of cataract surgery by 234,960 procedures (15.63%), an increase in YAG capsulotomy by 19,280 procedures (3.31%), and an increase in intravitreal injections by 146,320 procedures (3.86%).

CONCLUSION

Despite overall surgical volume increases among the ophthalmology procedures, angle-based stenting utilization decreased significantly with an accompanying trend change following the coding and reimbursement changes implemented in January 2022. Of the minimally invasive (microinvasive) glaucoma surgery procedures, goniotomy and canaloplasty counts increased the most between these periods. Trabeculectomy and glaucoma drainage device procedures continued to decrease, following well-established trends. Future studies are warranted to examine how these shifts in utilization may impact patient care outcomes.

Accuracy of swept source biometry device in detecting macular diseases compared with swept source OCT

OBJECTIVE

To assess the diagnostic accuracy of the IOLMaster 700 foveal scans to detect foveal pathology compared with a standard swept-source optical coherence tomography (SS-OCT) device.

RESULTS

One hundred seventy eye scans of 95 patients were included in the final analyses. Ninety-nine (58.2%) scans were classified as abnormal by SS-OCT. Mean sensitivity of the biometry device was 67.5% (range: 51-84%) and mean specificity was 69.5% (range: 44-95%). Intra-class correlation coefficients were 0.912 and 0.835, for reader 1 and 2, respectively. Area under the curve for receiver operating curve was 0.726. Foveal scans of the IOLMaster 700 can provide clinically useful information. Clinicians should pay attention to the macular scans when reviewing biometry prior to cataract surgery and standard macular OCT should ideally be supplemented in suspicious cases.

Usability of an artificially intelligence-powered triage platform for adult ophthalmic emergencies: a mixed methods study

There is growing demand for emergency-based eyecare services where the majority of those attending do not require urgent ophthalmic management. The Royal College of Ophthalmologists have recommended upskilling and supporting of allied health professionals to support eyecare delivery, where machine learning algorithms could help. A mixed methods study was conducted to evaluate the usability of an artificial intelligence (AI) powered online triage platform for ophthalmology. The interface, usability, safety and acceptability were investigated using a Think Aloud interview and usability questionnaires. Twenty participants who actively examine patients in ophthalmic triage within a tertiary eye centre or primary care setting completed the interview and questionnaires. 90% or more of participants found the platform easy to use, reflected their triage process and were able to interpret the triage outcome, 85% found it safe to use and 95% felt the processing time was fast. A quarter of clinicians reported that they have experienced some uncertainty when triaging in their career and were unsure of using AI, after this study 95% of clinicians were willing to use the platform in their clinical workflow. This study showed the platform interface was acceptable and usable for clinicians actively working in ophthalmic emergency triage.

The effect of mandatory post-call relief on sleep and wellness in ophthalmology residents

BACKGROUND

Multiple duty hour reforms have been implemented to optimize resident wellness through increasing opportunities for sleep recovery, but few studies have recorded objectively measured sleep or shown direct sleep and wellness benefits from such interventions. This study seeks to determine whether mandatory post-call relief policies with a partial night float system improved resident sleep, activity, and burnout among ophthalmology residents taking home call.

METHODS

We conducted a two group cohort study of ophthalmology residents at the University Washington comparing post graduate year-2 (PGY-2) resident sleep, activity, and burnout between the optional post-call relief group from July 1, 2017 to June 30, 2019 to the mandatory post-call relief group from July 1, 2019 to June 30, 2021.

RESULTS

Of twenty total residents participating in the survey portion, 18 residents participated in the sleep and activity tracking portion of the study, 9 in in the optional post-call relief cohort, and 9 in the mandatory post-call relief cohort. The mandatory post-call relief group recorded longer total sleep on call than the optional post-call relief group (p < 0.001). There was no difference in overnight sleep recorded on call (median 3.4 h), but residents recorded more time napping in the mandatory post-call relief cohort (p < 0.001). There was no significant difference between cohorts in amount of sleep while not on call. Residents in the mandatory post-call relief cohort recorded higher average daily steps, higher exercise time, and lower sedentary time than residents in the optional post-call relief cohort (p < 0.001). They also recorded lower median emotional exhaustion on the Maslach Burnout Inventory and lower stress in the Depression and Anxiety Stress Scale in the mandatory post-call relief cohort (p = 0.008).

CONCLUSIONS

Implementation of mandatory post-call relief policies with a partial night-float system among PGY-2 residents was associated with more post-call naps with more overall physical activity, lower emotional exhaustion scores, and lower stress scores, despite no changes to overnight sleep on call or total sleep. Although sample size limits interpretation of data, implementation of mandatory post call relief could be considered to improve post-call sleep in programs with home call.

[Chinese guideline for cataract surgery in adults (2023)]

Cataract is the leading cause of blindness worldwide. In recent years, the annual amount of adult cataract surgery is increasing rapidly. In order to promote the standardization of adult cataract surgery in our country, in accordance with the guiding principles and standards of clinical practice and the existing evidence-based data and expert consensus, Chinese Cataract and Refractive Surgery Society has developed the first clinical guideline in China specifically addressing the surgical treatment of adult cataracts. This guideline focuses on the major clinical issues encountered in adult cataract surgery and aims to provide guidance and reference for ophthalmologists in their clinical practice.

[The application of 3D bioprinting in ophthalmology]

On the basis of 3D printing technology, 3D bioprinting has emerged with great development potential and good prospects in the field of medicine and tissue engineering. With this technique, different types of cells and biomaterials can be precisely incorporated into 3D anatomical structures, achieving tissue substitutes with superior structures or functions. In recent years, great progress has been made in the application of 3D bioprinting in ophthalmology. This article reviews not only the differences between 3D printing and 3D bioprinting, but also the development, types, characteristics, application, and prospects of 3D bioprinting in the production of eye tissue engineering materials.

An innovative optics lab design for residency training in ophthalmology

Proper understanding of the optical function of the eye is the foundation of clinical understanding of ophthalmologists. Although teaching principals of optics has always been a part of ophthalmology residency curriculum, it seems that successful strategies other than lecture-based methods are needed to engage students and facilitate the understanding of optical principals. A collaborative team of physicists (optics Ph.D.), ophthalmologists and medical education experts designed an optics lab for ophthalmology residents to help them practically simulate different optical phenomena. The educational course consisted of 4 sessions of 90 min to practice the optical tests using the lab instruments. Each class consisted of 6-9 residents, divided into 3 groups with a fully equipped unit, and two mentors (an optics Ph.D. professor and an ophthalmology professor). A quasi-experimental design with pre-post test was used to evaluate the effectiveness of the training workshop in changing the ophthalmology residents' optical knowledge and attitude. Thirty-five residents participated in the study. The average score of residents' performance before the workshop was 5.21 (out of 100), which increased significantly to 66.1 after the workshop. Also, the average knowledge of residents, which was measured as self-reported, increased significantly from 28.85 to 71.09. The average score of students' attitudes and interest was increased from 40.49 to 74.81. It seems that training workshops and labs are effective to bring about change in knowledge and attitude of ophthalmology residents toward optics as a new teaching strategy that would be implemented in their curriculum.