A case of choroidal melanocytoma treated by transscleral resection: A clinicopathological study

Purpose

Choroidal melanocytoma is a rare benign melanocytic tumor. We report a case of choroidal melanocytoma that was definitively diagnosed by histopathological findings after local resection.

Observation

A 71-year-old female complained of blurred vision in her left eye. Her best-corrected visual acuity (BCVA) was 1.0. A dark-brown elevated lesion, measuring 5 papilla-diameter was found in the periphery of the fundus in her left eye. The mass showed hyperfluorescence on fluorescein angiography, early hypofluorescence and late hyperfluorescence on indocyanine green angiography. B-mode echography indicated the mass was originated from the choroid. Orbital magnetic resonance imaging showed isointense signal intensity on T1-weighted images (WI) and hypointense signal intensity on T2-WI, and poor Gadolinium enhancement on T1WI. The tumor was suspected to be melanocytoma, but it was difficult to differentiate from malignant melanoma. Transscleral tumor resection combined with 25-gauge vitrectomy was performed. Histopathological examinations led to the diagnosis of choroidal melanocytoma. Two years after local resection, her BCVA was 1.0 with no tumor recurrence.

Conclusions/importance

Local resection was useful as a diagnostic treatment for choroidal tumors confined to the periphery of the fundus that were difficult to clinically differentiate from malignant melanoma.

Comparative analysis of heavy metal content of unregulated facial whitening creams and branded facial whitening creams

The present study was conducted to evaluate potential health risks of Omani cosmetics considering the dangers and adverse effects on health caused by unregulated and unlabelled cosmetic products. Therefore, this current study is to examine the toxic heavy metals of unregulated facial whitening creams that are available in the Omani market and compare them with branded facial whitening creams. A total twenty-two samples were purchased from the Souqs/markets of all eleven governorates of Oman and their heavy metals content was determined by using Inductively Coupled Plasma-Optical Emission Spectroscopy (ICP-OES). The sample was digested by using ultra wave microwave at 180 °C. The percentage of heavy metals present in the unregulated whitening creams were compared with the heavy metals content of two randomly selected and branded whitening creams. The results showed that most of the unregulated samples contain significant amount of chromium, cooper and lead. In comparison, the branded face creams contained only the permissible amount of the heavy metals tested. The maximum arsenic content was found in a sample collected from Al Batinah South region (1.74 ppm). The maximum cadmium content was found in a sample collected from Al Wusta region (2.02 ppm). The maximum cobalt and chromium content were found in the samples collected from Al Buraimi region (0.10 ppm) and Dhofar region (8.04 ppm) respectively. In conclusion, unregulated face creams are not safe for human consumption because they contain significant levels of heavy metals that exceed the permissible limits.

Keratoconus characteristics and associations: A cross-sectional keratoconus study in western India (CKSWI)

PURPOSE

To study the clinical and tomographic characteristics and associations of keratoconus (KC) patients visiting a tertiary eye care hospital.

METHODS

This was a cross-sectional, observational study that included 242 newly diagnosed clinical KC patients. Detailed ocular and systemic history, visual complaints, habit of eye rubbing, best spectacle-corrected visual acuity (BSCVA), retinoscopy reflex, detailed slit-lamp examination and tomographic findings, and presence of any ocular and systemic associations were documented for the included patients. Severity of KC was further graded into stages 0, 1, 2, 3, and 4 according to the ABCD grading system.

RESULTS

The most common visual complaint was blurred vision (82.64%), followed by itching (48.76%), tearing (43.80%), and photophobia (41.32%). A total of 44.62% of patients had the habit of eye rubbing and 4.54% had a family history of KC. Most common clinical signs were scissor reflex (94.21%), Rizutti's sign (77.27%), corneal protrusion (69.83%), and Fleischer ring (67.35%). A total of 14.05% of patients had stage 0, 42.15% had stage 1, 19.83% had stage 2, 18.60% had stage 3, and 5.37% had stage 4 KC. Of these patients, 70.25% had a BSCVA visual acuity of ≥6/12 or better; 26.45% had a BSCVA of ≥6/60 to <6/12; and 3.30% had a BSCVA of <6/60. Ocular allergies, atopy, and asthma were found in 32.32%, 4.96%, and 2.48% cases, respectively.

CONCLUSION

This study gives an overview of the clinical findings of KC cases in western India. Our results suggest that use of retinoscopy should be promoted in early KC detection in primary eyecare screening programs.

Posterior segment manifestations of Takayasu arteritis: A narrative review

Ocular symptoms can be the presenting manifestation of Takayasu arteritis (TA) or could be indicative of disease reactivation. A review of published literature related to posterior segment manifestations of TA by using the keywords "Takayasu arteritis," "ophthalmic manifestations," "retina," "retinopathy," "ocular," "optic nerve," and "optic neuropathy" was performed. In total, 62 case reports and 12 case series were included. The majority of the articles were from Asia (n = 47, 64%). Females outnumbered males in the ratio of 7:1. The mean age of patients was 33 years (range: 8-78 years, SD: 13.5 years). In 58% (n = 41 out of 71) cases, ocular symptoms were the presenting manifestation of the underlying disease. Hypotensive retinopathy was found in 70% of eyes, and hypertensive retinopathy was found in 27%. The mean presenting visual acuity (VA) was +1.03 logMAR (range: -0.12 to 3, SD: 1.07), and at the final follow-up was +1.02 logMAR (range: -0.12 to 3, SD 1.17). VA improved in 34% (n = 29/86), remained stable in 45% (39/86), and worsened in 21% (18/86). The mean follow-up was 9 months (range: 0.5-204, SD: 16 months).

DEXAMETHASONE IMPLANT VERSUS TOPICAL CARBONIC ANHYDRASE INHIBITORS IN PATIENTS WITH BILATERAL RETINITIS PIGMENTOSA-RELATED CYSTOID MACULAR EDEMA: A Prospective, Paired-Eye Pilot Study

PURPOSE

To compare within-subject efficacy and safety of intravitreal dexamethasone implant and topical carbonic anhydrase inhibitors in the treatment of retinitis pigmentosa-related cystoid macular edema.

METHODS

Patients with bilateral retinitis pigmentosa-related cystoid macular edema were treated with intravitreal dexamethasone implant in one eye and topical carbonic anhydrase inhibitors in the contralateral eye. The primary endpoint was a change in central macular thickness. Secondary endpoints were changes in best-corrected visual acuity and microperimetric central retinal sensitivity. Intraocular pressure and other ocular complications were evaluated for safety assessment.

RESULTS

Nine patients were recruited for this 12-month follow-up study. Central macular thickness was significantly lower in intravitreal dexamethasone implant-treated eyes than in topical carbonic anhydrase inhibitors-treated eyes at Months 1 and 7, whereas mean best-corrected visual acuity was better in eyes treated with topical carbonic anhydrase inhibitors at Month 12 (borderline significant P = 0.0510). There was no difference in microperimetric sensitivity between the two treatments. Three patients developed ocular hypertension after intravitreal dexamethasone implant. Intravitreal dexamethasone implant showed an effect on the contralateral eye in five of nine patients.

CONCLUSION

Intravitreal dexamethasone implant was more effective than topical carbonic anhydrase inhibitors in reducing retinitis pigmentosa-related cystoid macular edema 1 month after treatment. Corticosteroids can play a key role in the management of retinitis pigmentosa-related cystoid macular edema; however, their routes, timing, and modes of administration should be further explored.

Management of macula-on giant retinal tear detachments- outcome of pars-plana-vitrectomy with silicone oil versus gas tamponade

BACKGROUND

To compare the outcome of eyes with a macula-on giant retinal tear (GRT) detachment treated with pars-plana-vitrectomy (PPV) depending on the used endotamponade.

METHODS

All consecutive cases with a macula-on GRT-associated rhegmatogenous retinal detachment (RRD) managed with PPV between 2007 and 2022 were retrospectively assessed depending on the selected endotamponade. By reviewing medical charts and surgical protocols the pre- and intraoperative parameters were analysed in detail. The number of vitreoretinal (VR) procedures needed for reattachment, the redetachment rate and the functional outcome were evaluated. Eyes treated with primary silicone oil (SO) tamponade were compared to eyes with primary gas tamponade. Cases with pre-existing conditions affecting outcome e.g. macula-off situation, history of trauma, status after complicated cataract surgery, former VR surgery or proliferative vitreoretinopathy grade C or higher were excluded.

RESULTS

Overall, 51 eyes of 45 patients with a macula-on GRT detachment were treated with PPV and SO (n = 32; 63%) or gas (n = 19; 37%) endotamponade in the observed period. Eyes with primary SO tamponade underwent on average 2.3 (SD 0.8) VR procedures and had a redetachment rate of 13% (n = 4). Eyes with gas tamponade showed a higher redetachment rate of 32% (n = 6) with a mean number of 1.6 (SD 1.0) PPV procedures. Postoperative best-corrected visual acuity (BCVA) was significantly better in eyes with primary gas tamponade (mean logMAR BCVA 0.32; SD 0.30) compared to eyes with SO (mean logMAR BCVA 0.60; SD 0.42; p = 0.008).

CONCLUSIONS

Surgical management of GRT-associated RRDs is complex. In clinical routine often SO is used as endotamponade. Because of known disadvantages (second procedure necessary for SO removal, unexplained SO-related visual loss, secondary glaucoma, SO emulsification) some VR surgeons prefer a gas tamponade. In our cohort, eyes with a gas compared to SO tamponade showed higher redetachment rates. However, the final postoperative BCVA was significantly better in eyes with gas compared to SO tamponade.

TRIAL REGISTRATION

The trial protocol was approved by the local ethics committee on 25th of November 2022 (Ethikkommission der Universität Regensburg, Votum 22-3166-104).

[Clinical approach for solid intraocular metastases]

BACKGROUND

Intraocular metastases arising from solid tumors are found in approximately 2% of patients with metastatic tumor diseases and are therefore more frequent than originally assumed. They often affect the uvea and are associated with a poor prognosis. Due to the difficult diagnosis and an inconsistent treatment regimen, ophthalmologists have a special responsibility here.

OBJECTIVE

This article gives a summary of the various types of intraocular metastases with respect to clinical features, diagnostics, treatment and prognosis as well as recommendations for follow-up care.

METHODS

A selective literature search was carried out on the topic of intraocular metastases using PubMed and Google Scholar.

RESULTS

Intraocular metastases most frequently affect the uvea, specifically the choroid. In most cases the underlying disease is breast or lung cancer, but other rarer primary tumors have also been reported in the literature. Metastatic lesions can show very different morphological manifestations but can be distinguished based on the corresponding structure of manifestation in the eye and with the aid of targeted staging, thus providing valid information on the type of primary tumor. The treatment is partly experimental and usually depends on the primary tumor and leading symptoms of the patient. A differentiation between a curative or palliative treatment situation must always be made.

CONCLUSION

Intraocular metastases are the most frequent intraocular tumor and are usually associated with a poor prognosis. Accurate diagnostics for finding the treatment as well as interdisciplinary collaboration and the presentation of the patient on the tumor board are essential.

Comparison of Two Presbyopia-Correcting Trifocal Intraocular Lenses: A Prospective Study

Objectives

To evaluate the clinical results of a new trifocal intraocular lens (IOL) with sinusoidal design by comparing with a traditional trifocal IOL.

Materials and Methods

A total of 79 patients undergoing uneventful microincisional cataract surgery with bilateral implantation of one of two types of trifocal IOLs, the Acriva Trinova IOL (VSY) or Acrysof IQ PanOptix IOL (Alcon), were enrolled in this prospective study. Visual and refractive outcomes, contrast sensitivity (CS), and defocus curve were assessed at 3 months after surgery. Patient satisfaction and incidence of photic phenomena were also evaluated.

Results

The number of patients/eyes were 48/96 in the Trinova group and 31/62 in the PanOptix group. There were no significant differences between the groups for monocular and binocular corrected/uncorrected distance or intermediate (at 60 cm) and near visual acuities (VA) postoperatively. The Trinova group had statistically significantly better intermediate VA at 80 cm than the PanOptix group (p<0.05). The CS results of both groups were within the normal limits. In the binocular defocus curve of both IOLs, we observed a peak of good VA at 0.0 diopters defocus and a useful wide range for intermediate distances. The incidence of photic phenomena in the Trinova group was lower at postoperative 1 month (p<0.05) but this difference disappeared at 3 months. A total of 47 patients (97.9%) in the Trinova group and 30 patients (96.7%) in the PanOptix group stated that they would recommend the same IOL.

Conclusion

Both trifocal IOLs provide good visual quality outcomes and patient satisfaction.

British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease

Sjögren disease (SD) is a chronic, autoimmune disease of unknown aetiology with significant impact on quality of life. Although dryness (sicca) of the eyes and mouth are the classically described features, dryness of other mucosal surfaces and systemic manifestations are common. The key management aim should be to empower the individual to manage their condition-conserving, replacing and stimulating secretions; and preventing damage and suppressing systemic disease activity. This guideline builds on and widens the recommendations developed for the first guideline published in 2017. We have included advice on the management of children and adolescents where appropriate to provide a comprehensive guideline for UK-based rheumatology teams.

Performance of anterior segment OCT-based algorithms in the opportunistic screening for primary angle-closure disease

Purpose

This study aimed to investigate the performance of deep learning algorithms in the opportunistic screening for primary angle-closure disease (PACD) using combined anterior segment parameters.

Methods

This was an observational, cross-sectional hospital-based study. Patients with PACD and healthy controls who underwent comprehensive eye examinations, including gonioscopy and anterior segment optical coherence tomography (ASOCT) examinations under both light and dark conditions, were consecutively enrolled from the Department of Ophthalmology at the Beijing Tongren Hospital between November 2020 and June 2022. The anterior chamber, anterior chamber angle, iris, and lens parameters were assessed using ASOCT. To build the prediction models, backward logistic regression was utilized to select the variables to discriminate patients with PACD from normal participants, and the area under the receiver operating characteristic curve was used to evaluate the efficacy of the opportunistic screening.

Results

The data from 199 patients (199 eyes) were included in the final analysis and divided into two groups: PACD (109 eyes) and controls (90 eyes). Angle opening distance at 500 μm, anterior chamber area, and iris curvature measured in the light condition were included in the final prediction models. The area under the receiver operating characteristic curve was 0.968, with a sensitivity of 91.74 % and a specificity of 91.11 %.

Conclusion

ASOCT-based algorithms showed excellent diagnostic performance in the opportunistic screening for PACD. These results provide a promising basis for future research on the development of an angle-closure probability scoring system for PACD screening.

Assessment by the Scheimpflug imaging system of corneal clarity and anterior segment properties in rosacea patients

OBJECTIVE

To evaluate the effects of rosacea on ocular surface changes such as alterations in dry eye parameters, corneal densitometry, and aberrations, in comparison with healthy controls.

METHODS

A total of 88 eyes of 44 patients diagnosed with rosacea and 88 eyes of 44 healthy controls were enrolled in this cross-sectional study. All participants underwent a comprehensive dermatologic and ophthalmic examination and Tear Break-Up Time (TBUT) and Schirmer-1 tests were performed. The rosacea subtype and Demodex count and OSDI scores of all participants were recorded. Corneal topographic, densitometric, and aberrometric measurements were obtained using the Scheimpflug imaging system.

RESULTS

The mean age of the 44 patients was 41.2 ± 11.0 years of whom 31 (70.5%) were female. The mean TBUT and Schirmer-1 test values were significantly decreased and OSDI scores were significantly increased in the rosacea group compared to healthy controls (p < 0.01 for all). The most common subtype of rosacea was erythematotelangiectatic rosacea (70.4%). The severity grading of rosacea revealed that 18 (40.9%) patients had moderate erythema. The median (min-max) Demodex count was 14.0 (0-120) and the disease duration was 24.0 (5-360) months. The comparison of the corneal densitometry values revealed that the densitometry measurements in all concentric zones, especially in central and posterior zones were higher in rosacea patients. Corneal aberrometric values in the posterior surface were also lower in the rosacea group compared to healthy controls. The topographic anterior chamber values were significantly lower in the rosacea group.

STUDY LIMITATIONS

Relatively small sample size, variable time interval to hospital admission, and lack of follow-up data are among the limitations of the study. Future studies with larger sample sizes may also enlighten the mechanisms of controversial anterior segment findings by evaluating rosacea patients who have uveitis and those who do not.

CONCLUSION

Given the fact that ocular signs may precede cutaneous disease, rosacea is frequently underrecognized by ophthalmologists. Therefore, a comprehensive examination of the ocular surface and assessment of the anterior segment is essential. The main priority of the ophthalmologist is to treat meibomian gland dysfunction and Demodex infection to prevent undesired ocular outcomes.

The socioeconomic epidemiology of inherited retinal diseases in Portugal

BACKGROUND

Inherited retinal diseases (IRDs) are a group of rare degenerative disorders of the retina that can lead to blindness from birth to late middle age. Knowing the target population and its resources is essential to better plan support measures. The aim of this study was to evaluate the socioeconomic characteristics of regions in Portugal where IRD patients reside to inform the planning of vision aid and rehabilitation intervention measures.

RESULTS

This study included 1082 patients from 973 families, aged 3 to 92 years, with a mean age of 44.8 ± 18.1 years. Patients living with an IRD were identified in 190 of the 308 municipalities. According to this study, the estimated IRD prevalence in Portugal was 10.4 per 100,000 inhabitants, and by municipalities, it ranged from 0 to 131.2 per 100,000 inhabitants. Overall, regions with a higher prevalence of IRD have a lower population density (r=-0.371, p < 0.001), a higher illiteracy rate (r = 0.404, p < 0.001) and an overall older population (r = 0.475, p < 0.001). Additionally, there is a lower proportion of doctor per capita (r = 0.350, p < 0.001), higher social security pensions beneficiaries (r = 0.439, p < 0.001), worse water quality for human consumption (r=-0.194, p = 0.008), fewer audiences at the cinema (r=-0.315, p < 0.001) and lower proportion of foreign guests in tourist accommodations (r=-0.287, p < 0.001).

CONCLUSION

The number of identified patients with IRD varied between regions. Using data from national statistics (PORDATA), we observed differences in socioeconomic characteristics between regions. Multiple targeted aid strategies can be developed to ensure that all IRD patients are granted full clinical and socioeconomic support.

Proteomic Profiling of Endothelial Cells Exposed to Mitomycin C: Key Proteins and Pathways Underlying Genotoxic Stress-Induced Endothelial Dysfunction

Mitomycin C (MMC)-induced genotoxic stress can be considered to be a novel trigger of endothelial dysfunction and atherosclerosis-a leading cause of cardiovascular morbidity and mortality worldwide. Given the increasing genotoxic load on the human organism, the decryption of the molecular pathways underlying genotoxic stress-induced endothelial dysfunction could improve our understanding of the role of genotoxic stress in atherogenesis. Here, we performed a proteomic profiling of human coronary artery endothelial cells (HCAECs) and human internal thoracic endothelial cells (HITAECs) in vitro that were exposed to MMC to identify the biochemical pathways and proteins underlying genotoxic stress-induced endothelial dysfunction. We denoted 198 and 71 unique, differentially expressed proteins (DEPs) in the MMC-treated HCAECs and HITAECs, respectively; only 4 DEPs were identified in both the HCAECs and HITAECs. In the MMC-treated HCAECs, 44.5% of the DEPs were upregulated and 55.5% of the DEPs were downregulated, while in HITAECs, these percentages were 72% and 28%, respectively. The denoted DEPs are involved in the processes of nucleotides and RNA metabolism, vesicle-mediated transport, post-translation protein modification, cell cycle control, the transport of small molecules, transcription and signal transduction. The obtained results could improve our understanding of the fundamental basis of atherogenesis and help in the justification of genotoxic stress as a risk factor for atherosclerosis.

Cysts and tumours of the iris: Diagnostic tools and key management considerations-A review

The iris is a unique structure, with exquisite variations in colour and form. Pathological changes, specifically including iris cysts and tumours are relatively uncommon, difficult to diagnose, and yet potentially blinding or life-threatening. Based on a comprehensive literature review, with highly illustrated key case examples, this report aims to guide the clinician in filtering the differential diagnoses of iris cysts and tumours. Evaluation is in the context of key diagnostic clinical tools and management considerations. Diagnostic imaging techniques include serial anterior segment photography, ultrasound, anterior segment optical coherence tomography, and iris fluorescein angiography, however, the roles of computerised topography and magnetic resonance imaging are also considered in this review. Management includes categorisation in terms of solid iris tumours (melanocytic vs. non-melanocytic), or iris cysts (primary vs. secondary) that may be usefully differentiated by clinical assessment, avoiding more invasive interventions. Cystic lesions are generally benign, although implantation cysts in particular cause significant complications and surgical challenges. Most solid tumours are melanocytic and also typically benign. However, in larger lesions, rapid growth, symptoms and complications more likely indicate malignancy, requiring further investigation.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument

PURPOSE

To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery.

METHODS

A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts.

RESULTS

The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly.

CONCLUSION

A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Long-term surgical outcomes of one-muscle vs. two-muscle horizontal strabismus surgery

PURPOSE

While horizontal strabismus surgery is generally considered to have favorable outcomes, success rates can vary by type of procedure. Our purpose is to compare the long-term outcomes of patients who underwent one-muscle vs. two-muscle horizontal strabismus surgery.

METHODS

This is a retrospective study comparing one-muscle to two-muscle strabismus surgery for small to moderate angle horizontal strabismus. Demographic data and eye exam parameters were compared at baseline and postoperatively (6 months up to 6 years). Surgical success was defined as a post-operative angle of 10 PD or less. We also compared outcomes by strabismus type: esotropia vs exotropia and adjusted the analysis for previous strabismus surgery.

RESULTS

Out of 89 patients with moderate angle horizontal strabismus (25 PD or less), 17 patients had a one-muscle operation, and 72 patients had two-muscle surgery. The mean age was 14.12 ± 9.30 years and 11.70 ± 11.30 years for the one-muscle and two-muscle groups, respectively (p = .74). The baseline characteristics of both groups were comparable. Follow-up time was 32.82 ± 26.93 months in one-muscle and 37.67 ± 23.81 in two-muscle groups (p = .29). Success rate was 70.6% for the one-muscle group and 68.10% for the two-muscle group (p = .69). Outcomes were similar when divided into esotropia and exotropia. The success rate was not affected by previous strabismus surgeries nor by the initial angle of deviation.

CONCLUSION

One-muscle and two-muscle horizontal strabismus surgery had similar long-term outcomes and did not differ by strabismus type nor by angle of deviation.

Determination of Refractive Error Using Direct Ophthalmoscopy in Children

Purpose

Refractive error is a major cause of visual impairment in children and its early detection can prevent ocular morbidity such as amblyopia and strabismus. Brückner test is a comprehensive test which can be easily administered in children using a direct ophthalmoscope. We aimed to determine refractive error in children by analysis of the red reflex using modified Brückner test.

Patients and Methods

This prospective observational study was conducted on 683 undilated eyes of 683 children aged four to 10 years. They were evaluated with a direct ophthalmoscope from one meter in a dimly lit room. The characteristics of the red reflex and crescent obtained were compared with photoscreener refraction value and analyzed.

Results

The presence of superior crescent was associated with hypermetropia (Chi square 37.11, p < 0.001, kappa = 0.15) and inferior crescent with myopia (Chi square 157.29, p < 0.001, kappa = 0.477). Superior crescent was 98.4% sensitive in detecting hypermetropia. Hypermetropia greater than +1.5D, was associated with larger superior crescent crossing horizontal midline of pupil (Chi square = 5.29, p = 0.021).

Conclusion

The modified Brückner test is useful in detection and quantification of refractive error in children. It is easy, simple, quick and can be employed in the community as a screening test to detect potentially amblyogenic refractive errors.

Generalizability of Deep Neural Networks for Vertical Cup-to-Disc Ratio Estimation in Ultra-Widefield and Smartphone-Based Fundus Images

Purpose

To develop and validate a deep learning system (DLS) for estimation of vertical cup-to-disc ratio (vCDR) in ultra-widefield (UWF) and smartphone-based fundus images.

Methods

A DLS consisting of two sequential convolutional neural networks (CNNs) to delineate optic disc (OD) and optic cup (OC) boundaries was developed using 800 standard fundus images from the public REFUGE data set. The CNNs were tested on 400 test images from the REFUGE data set and 296 UWF and 300 smartphone-based images from a teleophthalmology clinic. vCDRs derived from the delineated OD/OC boundaries were compared with optometrists' annotations using mean absolute error (MAE). Subgroup analysis was conducted to study the impact of peripapillary atrophy (PPA), and correlation study was performed to investigate potential correlations between sectoral CDR (sCDR) and retinal nerve fiber layer (RNFL) thickness.

Results

The system achieved MAEs of 0.040 (95% CI, 0.037-0.043) in the REFUGE test images, 0.068 (95% CI, 0.061-0.075) in the UWF images, and 0.084 (95% CI, 0.075-0.092) in the smartphone-based images. There was no statistical significance in differences between PPA and non-PPA images. Weak correlation (r = -0.4046, P < 0.05) between sCDR and RNFL thickness was found only in the superior sector.

Conclusions

We developed a deep learning system that estimates vCDR from standard, UWF, and smartphone-based images. We also described anatomic peripapillary adversarial lesion and its potential impact on OD/OC delineation.

Translational Relevance

Artificial intelligence can estimate vCDR from different types of fundus images and may be used as a general and interpretable screening tool to improve community reach for diagnosis and management of glaucoma.

Priorities in school eye health in low and middle-income countries a scoping review

School eye health (SEH) has been on the global agenda for many years, and there is mounting evidence available to support that school-based visual screenings are one of the most effective and cost-efficient interventions to reach children over five years old. A scoping review was conducted in MEDLINE, Web of Science, PubMed, and CINHAL between February and June 2023 to identify current priorities in recent literature on school eye health in low- and middle-income countries (LMICs). Selection of relevant publications was performed with Covidence, and the main findings were classified according to the WHO Health Promoting Schools framework (HPS). A total of 95 articles were included: cross-sectional studies (n = 55), randomised controlled trials (n = 7), qualitative research (n = 7) and others. Results demonstrate that multi-level action is required to implement sustainable and integrated school eye health programmes in low and middle-income countries. The main priorities identified in this review are: standardised and rigorous protocols; cost-effective workforce; provision of suitable spectacles; compliance to spectacle wear; efficient health promotion interventions; parents and community engagement; integration of programmes in school health; inter-sectoral, government-owned programmes with long-term financing schemes. Even though many challenges remain, the continuous production of quality data such as the ones presented in this review will help governments and other stakeholders to build evidence-based, comprehensive, integrated, and context-adapted programmes and deliver quality eye care services to children all over the world.

Perceptions of online surgical-focused learning amongst surgeons during the COVID pandemic: A scoping review 2020-22

INTRODUCTION

During the COVID pandemic many centres adopted e-learning as a tool to adhere to social distancing recommendations while continuing to provide ongoing postgraduate medical education. We aimed to complete this scoping review in order to map experience and perceptions amongst surgeons and surgical trainees to remote learning during the COVID pandemic.

METHODS

Using Arksey and O'Malley's five step model for conducting a scoping review, a systematic search strategy was undertaken across three online databases SCOPUS, MEDLINE and Web of Science. Only original articles in English in the field of postgraduate education in surgery were included.

RESULTS

44 studies were selected for review. Of these 44, 21 were studies of perception of a newly developed e-learning tool/platform. 17 were surveys of surgeon's attitudes towards e-learning during the COVID pandemic. The remaining 6 studies were studies of knowledge or skills acquired through new e-learning, which included a survey of experience. The United States was the most common country of origin with General Surgery the most represented surgical speciality. Response rates across all three study subgroups were on average >60%. Surgeon's experience of e-learning was reported in only positive terms in 86% (n = 38/44) of studies.

CONCLUSIONS

This paper is informative in that it focuses specifically on surgeons' perceptions of a e-learning tools used in addition to skills or knowledge gained. Positive e-learning experience reported in these studies may lead to more blended learning curriculums being developed, deployed and evaluated going forward.

Modified sutureless and glue-free method versus conventional sutures for conjunctival autograft fixation in primary pterygium surgery: a systematic review and meta-analysis

BACKGROUND

Pterygium is a common ocular surface disorder that requires surgical intervention for treatment. Conjunctival autografts are preferred over simple excision due to lower recurrence rates. This systematic review and meta-analysis compared the modified sutureless glue-free (MSGF) method with conventional sutures (CS) for conjunctival autograft fixation in primary pterygium surgery.

METHODS

A comprehensive search was conducted in MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov for randomised controlled trials (RCTs) comparing MSGF and CS conjunctival autografts. Outcome measures included operation time, recurrence and postoperative complications. Standardised mean difference (SMD) and risk ratio (RR) were used for continuous and dichotomous outcomes, respectively.

RESULTS

11 RCTs involving 833 participants were included. The analysis revealed that MSGF had a significantly shorter operation time compared with CS (SMD -3.704, 95% CI -5.122 to -2.287, p<0.001). CS was associated with a higher risk of foreign body sensation (RR 0.22, 95% CI 0.06 to 0.74, p=0.01). MSGF was associated with a higher risk of graft dehiscence (RR 9.01, 95% CI 2.74 to 29.68, p=0.000) and graft retraction (RR 2.37, 95% CI 1.17 to 4.77, p=0.02). No significant differences were found in recurrence, graft haemorrhage, granuloma, Dellen and conjunctival oedema.

CONCLUSION

Using the MSGF technique in conjunctival autograft fixation for pterygium surgery reduces operation time by relying solely on the patient's blood for fixation. However, it increases the risk of graft dehiscence and retraction. However, CS is linked to a higher likelihood of experiencing foreign body sensations. Understanding the learning curve and surgeon familiarity with novel techniques is crucial for optimising patient care and surgical outcomes, while individualised decision-making is necessary considering the advantages and disadvantages of each approach. Further research is warranted to minimise complications and optimise surgical outcomes.

Outcome of patients with traumatic cranial nerve palsy admitted to a university hospital in Nepal

BACKGROUND

Cranial nerve palsy (CNP) is a common complication of traumatic brain injury (TBI). Despite a high incidence of TBI in Nepal (382 per 100,000), literature on the specific management and outcome of CNP is lacking. This study aimed to examine the outcomes of TBI patients involving single versus multiple CNP.

METHODS

A retrospective chart review of 170 consecutive TBI patients admitted to the tertiary neurosurgical center in Nepal between April 2020 and April 2022 was conducted. Demographic, clinical, and etiological characteristics; imaging findings; and management strategies were recorded, compared, and analyzed using descriptive statistics. The Glasgow Outcome Scale Extended (GOSE) was used to measure the outcomes in two groups of patients (single and multiple CNP) at 3 months.

RESULTS

Out of 250 eligible patients, 80 were excluded and CNP was noted in 29 (17.1%) of the remaining 170. The median age was 34.9 years, and falls (60.6%) were the most common cause of trauma. TBI severity was categorized based on GCS: mild (82.4%), moderate (15.9%), and severe (1.8%). Cranial nerve involvement was seen in 29 (17.05%) patients: single cranial nerve involvement in 26 (89.65%) and multiple nerve involvement in 3 (10.34%). The most common isolated cranial nerve involved was the oculomotor nerve (37.9%). CT findings revealed a maximum of skull fractures with no significant association between CNP and CT findings.

CONCLUSIONS

CNP is a common consequence of TBI with the most common etiology being falls followed by RTA. Single CNP was more common than multiple CNP with no significant difference in the outcome in the 3-month GOSE score. Further research is needed to determine the burden of traumatic CNP and establish specific management guidelines for different types of CNP.

Prognostic Significance of Tumor-Infiltrating Lymphocytes and High-Risk Human Papillomavirus in Ocular Sebaceous Carcinoma: A Comprehensive Analysis

High-risk human papillomavirus (hrHPV) and tumor-infiltrating lymphocytes (TILs) are known to have prognostic significance in oropharyngeal squamous cell carcinoma. However, their significance in ocular sebaceous carcinoma (OSC) remains unverified because of the rarity of the condition. This study aimed to investigate the association between clinicopathologic features, biomarkers, and hrHPV infection and their potential to predict prognosis in OSC patients. We analyzed the clinicopathologic features of 81 OSC patients from Asan Medical Center between 2000 and 2022. Seventeen biomarkers and hrHPV were examined using immunohistochemistry and DNA in situ hybridization on tissue microarray cores. hrHPV was identified in 31 cases (38.3%). Univariate analysis revealed that hrHPV infection was associated with comedonecrosis (P = .032), high Ki-67 labeling index (≥30%, P = .042), lower expression of E-cadherin (P = .033), and loss of expression of zinc finger protein 750 (P = .023). Multivariate analysis revealed that loss of expression of zinc finger protein 750 (P = .026) remained an independently associated factor for hrHPV. Progression-free survival analysis was performed on 28 patients who were continuously observed for more than 5 years. During a median follow-up duration of 86 months, recurrence or metastasis developed in 14 patients (50%) within the survival cohort, occurring at a median time of 48 months after excision. Univariate analysis indicated that recurrence or metastasis was associated with tumor size (P = .010), high TILs (≥10%; P = .025), lymphovascular invasion (P = 0.043), site of origin (P = .025), and high expression of bcl-2-associated athanogene 3 (P = .039). Multivariate analysis demonstrated that high TILs (P = .017) and site of origin (P = .025) were independent prognostic factors. The prognosis of OSC was hrHPV-independent, and a better prognosis was associated with the site of origin in the order of the gland of Zeis, meibomian gland, and multicentric site, as well as with high TILs.

Combination of self-assembling system and N,O-carboxymethyl chitosan improves ocular residence of anti-glaucoma drug

Glaucoma is known to be one of the principal causes of vision loss due to elevated intraocular pressure. Currently, latanoprost eye drops is used as first-line treatment for glaucoma; however, it possesses low bioavailability due to rapid precorneal clearance. A novel delivery system with a mucoadhesive property could overcome this problem. Therefore, we attempt to develop a combination of self-assembling latanoprost nanomicelles (Latcel) and a mucoadhesive polymer (N,O-carboxymethyl chitosan: N,O-CMC) to improve the corneal residence time. Latcel was developed using Poloxamer-407 by thin film hydration method, followed by the addition of N,O-CMC using simple solvation to obtain Latcel-CMC and characterized using various physicochemical characterization techniques. The particle size of Latcel-CMC was 94.07 ± 2.48 nm and a zeta potential of -16.03 ± 0.66 mV, with a sustained release for 24h whereas marketed latanoprost drops released 90 % of the drug within 1h. In vitro cytotoxicity studies, HET-CAM, and in vivo Draize test showed the biocompatibility of Latcel-CMC. Cellular uptake studies performed using fluorescein isothiocyanate (FITC) loaded nanomicelles in human corneal epithelial cells indicates the increased cellular uptake as compare to plain FITC solution. In vivo ocular residence time was evaluated in Wistar rats using Indocyanine green (ICG) loaded nanomicelles by an in vivo imaging system (IVIS), indicating Latcel-CMC (8h) has better residence time than plain ICG solution (2h). The Latcel-CMC showed improved corneal residence time and sustained release of latanoprost due to increased mucoadhesion. Thus, the developed N,O-Carboxymethyl chitosan based nanomicelles eye drop could be a better strategy than conventional eye drops for topical delivery of latanoprost to treat glaucoma.

Periocular Sebaceous Carcinoma: A Case Audit from the National Specialist Ophthalmic Pathology Service in Liverpool from 2009 to 2022 to Assess the Diagnostic Utility of PRAME Expression

Introduction

Periocular sebaceous carcinoma (PSC) remains a common diagnostic pitfall both clinically and histomorphologically. PRAME (preferentially expressed antigen in melanoma) has been studied in the various neoplasms as proposed as diagnostic and therapeutic markers. PRAME is expressed in normal sebaceous units and in some sebaceous lesions; however, its utility in sebaceous carcinoma diagnosis has not yet been extensively investigated. We conducted a 13-year retrospective review of the patients diagnosed with PSC at the National Specialist Ophthalmic Pathology Service in Liverpool. Herein, we report the histomorphological and immunohistochemical (IHC) features of these tumors, particularly PRAME expression in this cohort.

Methods

Thirty-one PSC cases diagnosed between 2009 and 2022 were retrieved from the histopathology archives. Twenty cases diagnosed as invasive PSC and 11 cases with in situ PSC were included. The hematoxylin and eosin (H&E) slides and previously performed IHC slides were reviewed; clinical information data were obtained. Cases with an adequate tissue were also stained for PRAME (preferentially expressed antigen in melanoma) and adipophilin (if not already performed).

Results

In total, there were 24 females and 7 males diagnosed with PSC, ranging from 55 to 90 years (median, 78 years). The types of specimens received were 11 conjunctival mapping biopsies, 19 excisions/wedge resections, and 1 orbital exenteration. The eyelid was the commonest site involved (n = 24), followed by eyelid with conjunctiva (3), and conjunctiva alone (4). All patients presented with the clinical suspicion of malignancy. Histologically, 11 invasive PSC (55%) exhibited poorly differentiated morphology, composed of predominantly atypical basaloid cells with minimal sebocytic differentiation; 9 cases (45%) were moderately differentiated with noticeable finely multivacuolated cytoplasm; and 3 (15%) showed associated comedo necrosis. Most invasive PSC showed moderate-to-brisk mitotic activities. Of those cases with available immunostains (n = 31), 25 (80.6%) expressed adipophilin; 18 (58.1%) Ber-EP4; 14 (45.2%) epithelial membrane antigen (EMA); and 5 (16.1%) both androgen receptor and perforin positivity. PRAME expression was seen in normal sebaceous glands; however, only (5/19; 26%) of invasive PSC showed focal weak-to-moderate PRAME positivity, and mostly in moderately differentiated tumors. None of the in situ PSCs were PRAME-positive.

Conclusions

Most PSCs are moderate-to-poorly differentiated. Although PRAME is expressed in normal sebaceous units, it appears less useful as diagnostic marker for PSC, especially in poorly differentiated tumors. In difficult cases, panels of IHC studies (adipophilin, Ber-EP4, and EMA) achieve a definitive diagnosis.

Long-term outcomes of Mitomycin-C augmented trabeculectomy using subconjunctival injections versus soaked sponges: a randomised controlled trial

PURPOSE

To compare the safety and efficacy of subconjunctival injection of Mitomycin C(MMC) with sponge-applied MMC during trabeculectomy.

METHODS

This prospective, randomised, interventional study was conducted on consecutive patients with uncontrolled glaucoma. 137 patients were randomised into an Injection group (Group 1, n = 66) and a sponge group (Group 2, n = 71). Trabeculectomy was performed in all patients who were followed up on days 1, 15, 30, 3 months, 6 months, 1 year, 2 years & 3 years postoperatively. Baseline & follow-up visits were compared to find out difference in the number of antiglaucoma medications (AGM), Intraocular pressure (IOP), and Best Corrected Visual Acuity (BCVA). In Group 1, the surgeon used MMC 0.2 mg/ml as subconjunctival injection and two separate semicircular surgical sponges soaked with MMC solution of 0.2 mg/mL were inserted subconjunctivally in Group 2.

RESULTS

Mean preop IOP was 34.21 ± 13.3 mmHg & 34.17 ± 10.6 mmHg in group 1 & 2 respectively, which reduced to 11.34 ± 3.7& 12.57 ± 4.7 mmHg(6 months),11.97 ± 4.2 & 13.60 ± 5.3 mmHg(1 year),12.42 ± 4.4 & 11.77 ± 2.8 mmHg (2 years) &11.25 ± 3.2 & 11.81 ± 3.2 mmHg at final visit(P < 0.001 in both groups)with no significant difference between the groups. The mean number of preoperative AGM was 2.32 ± 0.7 & 2.32 ± 0.8 in group1 & 2 respectively which reduced to 0.78 ± 0.9 (P < 0.001) & 1.13 ± 1.1(P = 0.930) at 3 years. Overall success rates were 75.3% in group 1 and 70.7% in group 2 at 3 years(p = 0.512). Postoperative complications and the final post-operative visual outcomes were similar between the groups.

CONCLUSION

Subconjunctival Injection of MMC is as safe and effective as sponge application with comparable surgical outcomes and complications in the long term.

Scleral-fixated vs Iris-fixated intraocular lens in pediatric ectopia lentis: A systematic review

Numerous intraocular lens (IOLs) options are available for treating pediatric ectopia lentis, and this paper reviews recent literature on pediatric ectopia lentis treatment with iris-fixated and scleral-fixated IOLs. A comprehensive search was undertaken on PubMed, Embase, ProQuest, Cochrane, Wiley, SCOPUS, and EBSCO. Studies published in the last ten years that met the inclusion criteria were included in this review. Seventeen studies exhibiting low to moderate risk of bias were included in this review, with eight on iris-fixated IOL (IFIOL), six on scleral-fixated IOL (SFIOL), and three on both IOLs. From the included studies, these data were extracted and compared: best-corrected visual acuity, endothelial cell density, postoperative complications, IOL stability, and intraocular pressure. IFIOL and SFIOL show comparable lens stability, offer good visual rehabilitation, and demonstrate equivalent safety profiles. There is no discerning superiority between IFIOL and SFIOL in treating pediatric ectopia lentis. The choice of which IOL to implant depends on the surgeon's preference.

Choroidal hypertransmission width on optical coherence tomography: a prognostic biomarker in idiopathic macular hole surgery

PURPOSE

To test the hypothesis that optical coherence tomography (OCT) choroidal hypertransmission width (CHW) is a prognostic biomarker in idiopathic macular hole (MH) surgery METHODS: Retrospective cohort study of consecutive patients undergoing successful pars plana vitrectomy for idiopathic MH. We collected demographic, clinical, and OCT variables at the preoperative and last available visits. Two investigators assessed the following OCT parameters: MH minimum diameter, base diameter, CHW, ellipsoid zone, and external limiting membrane status (absent vs. present). Delta CHW was calculated as the difference between CHW and MH minimum diameter. Linear models were used to investigate factors associated with postoperative best-corrected visual acuity (BCVA) and BCVA change.

RESULTS

Thirty-six eyes (36 patients) with a median (interquartile range (IQR)) follow-up of 9 (8-11) months were included. The median BCVA (IQR) improved from 0.75 (1-0.6) logMAR preoperatively to 0.2 (0.6-0.1) logMAR at the last visit (p < 0.001). Preoperative MH minimum diameter (for a 10-μm increase, estimate (standard error (SE)): 0.009 (0.003) logMAR, p = 0.003), base diameter (for a 10-μm increase, 0.003 (0.001) logMAR, p = 0.032), CHW (for a 10-μm increase, 0.008 (0.002) logMAR, p < 0.001), and delta CHW (for a 10-μm increase, 0.013 (0.005) logMAR, p = 0.009) were significantly associated with postoperative BCVA. The proportion of variance explained was the highest for MH CHW (R2 0.35), followed by minimum MH diameter (R2 0.24), delta CHW (R2 0.19), and MH base diameter (R2 0.14). None of the study variables was associated with delta BCVA.

CONCLUSION

Preoperative CHW is associated with postoperative visual acuity in patients undergoing successful idiopathic MH surgery and may be a useful OCT prognostic biomarker.

Retinal injury from a laser skin resurfacing device during medical tourism: a public health concern

BACKGROUND

Laser skin resurfacing is a popular cosmetic procedure for noninvasive skin rejuvenation. Since health insurance plans often do not cover these types of procedures, patients often pay out of pocket. Consequently, there is an incentive to go abroad, where prices are more affordable. However, practitioners in destination countries may lack rigorous training on laser safety, regulatory oversight, or licensing, especially on devices used for "cosmetic" procedures. In certain cases, this can lead to tragic outcomes, especially when underqualified practitioners operate medical-grade laser devices.

CASE PRESENTATION

A 29-year-old woman suffered a retinal burn from a handheld Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser pulse device used to perform skin resurfacing treatment at a medical spa in Vietnam. The patient was not adequately informed about the potential risk to her vision and was not provided with any eye protection. A momentary, unintended laser exposure to the patient's right eye led to irreversible vision loss due to a macular burn. This incident caused immediate pain, followed by the sudden appearance of floaters, along with a retinal and vitreous hemorrhage. Despite treatment with off-label bevacizumab for the development of a choroidal neovascular membrane, vision remained at the level of counting fingers because of the presence of the macular scar.

CONCLUSION

When utilizing laser-based devices, it is crucial to employ safety measures, such as the wearing of safety goggles or the use of eye shields to protect ocular tissues from potential damage. The growing availability of cosmetic laser devices presents a substantial public health risk, because numerous operators lack adequate training in essential safety standards, or they neglect to follow them. Furthermore, patients seeking services abroad are subject to the regulatory practices of the destination country, which may not always enforce the requisite safety standards. Further research is needed to determine regional and global incidence of laser-related injuries to help direct educational and regulatory efforts.

Retinal detachment with multiple macrocysts in Stickler syndrome: case report and review of the literature

Background

Stickler syndrome is a hereditary connective tissue disorder associated with ocular, orofacial, musculoskeletal, and auditory impairments. Its main clinical characteristics include retinal detachment, hearing loss, and midface underdevelopment. In clinical practice, macrocyst is rarely reported in retinal detachment cases with Stickler syndrome.

Case presentation

We report the case of a 7-year-old child who developed a rhegmatogenous retinal detachment (RRD) in the right eye, accompanied by multiple peripheral macrocysts. The detachment was successfully surgically repaired with vitrectomy, retinal laser photocoagulation, cryotherapy and silicone oil tamponade. During the operation, a mini-retinectomy in the outer layer of each macrocyst was made for vesicular drainage and retinal reattachment. Genetic testing identified a pathogenic point mutation variant (c.1693C>T; p.Arg565Cys) in exon 26 of the COL2A1 gene. Six-months after the operation, the retina remained attached with improvement of best corrected visual acuity to 20/200.

Conclusion

Patients with Stickler syndrome may develop RRD of different severity. Macrocyst is rarely reported in previous literature of Stickler syndrome. In this case report, we share our experience in treating with multiple macrocysts in RRD and emphasize the importance of periodic follow-up for patients with Stickler syndrome.

Demographic and Clinical Profile of Pediatric Uveitis in Delta Region, Egypt

PURPOSE

Pediatric uveitis poses unique challenges, characterized by difficulties in performing comprehensive examinations, potential delays in diagnosis, and a heightened risk of ocular complications. This study evaluate the etiologic and clinical characteristics of uveitis in children presenting to the Mansoura Ophthalmic Center, Mansoura, Egypt.

METHODS

A cross-sectional observational study was undertaken involving children diagnosed with uveitis attending the uveitis outpatient clinic at Mansoura University Ophthalmic Center. Comprehensive clinical evaluations were carried out, including detailed history taking and exhaustive ophthalmological examinations. Whenever deemed necessary, Spectral Domain Optical Coherence Tomography (OCT) and Fluorescein Fundus Angiography (FFA) were utilized to secure retinal images. An extensive systemic evaluation was also conducted to discern the diverse causes of uveitis among the participants.

RESULTS

The cohort comprised 63 children, impacting 97 eyes. Bilateral involvement was seen in 54% of cases, with a male predominance of 58.7%. The predominant etiologies of uveitis were presumed trematode-induced (36.7%), Juvenile Idiopathic Arthritis (JIA) accounting for 28.6%, and in 12.7% of cases, the cause remained undetermined. Anterior uveitis emerged as the primary presentation in 79.4% of cases. Regarding visual loss, cataract was the leading cause at 56.4%, followed by vitritis at 38.4%, and macular edema at 20.5%.

CONCLUSION

Anterior uveitis was the most frequent presentation in our pediatric cohort. Despite the challenges, the majority of children with uveitis exhibited no significant visual impairment, with most causes of visual loss being reversible.

Applications of topical immunomodulators enhance clinical signs of vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC): a meta-analysis

PURPOSE

This meta-analysis aimed to review the safety and efficacy of topical cyclosporine A (CsA) and topical tacrolimus in allergic eye disease.

METHODS

A systematic search identified thirteen studies and a total of 445 patients for inclusion, making this the largest meta-analysis published on the subject. The current review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Thirteen randomized control trials were included in the meta-analysis. Eleven studies used CsA as the treatment, and two used Tacrolimus. In total, 445 participants were included, of whom 76.6% were male. The mean age of participants across the included studies was 14 years. All studies reported clinical signs as evaluated by an examining clinician. Signs were usually assessed by anatomical region, with the most common regions being the conjunctiva and the cornea, and the most common signs assessed were hyperemia and papillae. Three studies accounted for more than 50% of the meta-analysis's weight. Effect size (d) ranged from - 2.37 to - 0.03, negative values favoring immunomodulators. Fixed Effect Meta-Analysis returned an SMD of - 0.81 (95% CI [- 0.98, - 0.65]). However, there was significant heterogeneity (I2 = 61%, Qw = 30.76) in the outcome measure (P = 0.0021); therefore, a random-effect meta-analysis was also completed in which the pooled SMD was - 0.98 (95% CI [- 1.26, - 0.69], τ2 = 0.16).

CONCLUSIONS

This study affirms the current scientific community's stance that immunomodulators effectively treat clinical signs, including blepharitis, conjunctival hyperemia, edema, papillae, and corneal damage in severe ocular allergic disease.

Comparing the efficacy of glucocorticoids and anti-VEGF in treating diabetic macular edema: systematic review and comprehensive analysis

Introduction

The aim of this study was to better understand the efficacy of various drugs, such as glucocorticoids and anti-vascular endothelial growth factors (VEGF), in the treatment of diabetic macular edema (DME), and to evaluate various clinical treatment regimens consisting of different therapeutic measures.

Methods

This study included randomized controlled trials up to February 2023 comparing the efficacy of corticosteroid-related therapy and anti-VEGF therapy. PubMed, the Cochrane Library, and Embase were searched, and the quality of the studies was carefully assessed. Finally, 39 studies were included.

Results

Results at 3-month followup showed that intravitreal injection of bevacizumab (IVB) + triamcinolone acetonide (TA) was the most beneficial in improving best-corrected visual acuity and reducing the thickness of macular edema in the center of the retina in patients with DME. Results at 6-month follow-up showed that intravitreal dexamethasone (DEX) was the most effective in improving patients' bestcorrected visual acuity and reducing the thickness of central macular edema.

Discussion

Overall, IVB+TA was beneficial in improving best-corrected visual acuity and reducing central macular edema thickness over a 3-month follow-up period, while DEX implants had a better therapeutic effect than anti-VEGF agents at 6 months, especially the patients with severe macular edema and visual acuity impaired.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=397100, identifier CRD42023397100.

Optic neuritis secondary to syphilis

Optic neuritis is a rare manifestation of syphilis, and the involvement of the central nervous system should be considered synonymous with neurosyphilis. This infectious disease, well known as the great imitator, can affect any structure and produce multiple clinical symptoms. Here, we report a case of a 62- year-old male patient who presented to our service with decreased vision and myodesopsias in right eye. The posterior segment showed a hyperemic nerve with peripapillary hemorrhages and retinal pigment epithellium hyperplasia. The patient was recently diagnosed with HIV. Serology for syphilis was positive with posterior decreased levels of nontreponemal test following treatment with ceftriaxone. Optic neuritis can occur at any stage of syphilis and must always be considered a differential diagnosis.

Narrative review after post-hoc trial analysis of factors that predict corneal endothelial cell loss after phacoemulsification: Tips for improving cataract surgery research

PURPOSE

Identifying pre/perioperative factors that predict corneal endothelial-cell loss (ECL) after phacoemulsification may reveal ways to reduce ECL. Our literature analysis showed that 37 studies have investigated one or several such factors but all have significant limitations. Therefore, the data of a large randomized controlled trial (PERCEPOLIS) were subjected to post-hoc multivariate analysis determining the ability of nine pre/perioperative variables to predict ECL.

METHODS

PERCEPOLIS was conducted in 2015-2016 to compare two phacoemulsification techniques (subluxation and divide-and-conquer) in terms of 3-month ECL. Non-inferiority between the techniques was found. In the present study, post-hoc univariate and multivariate analyses were conducted to determine associations between ECL and age, sex, cataract density, preoperative endothelial-cell density, phacoemulsification technique, effective phaco time (EPT), and 2-hour central-corneal thickness. The data are presented in the context of a narrative review of the literature.

RESULTS

Three-month data were available for 275 patients (94% of the randomized cohort; mean age, 74 years; 58% women). Mean LOCSIII cataract grade was 3.2. Mean EPT was 6 seconds. Mean ECL was 13%. Only an older age (beta = 0.2%, p = 0.049) and higher EPT (beta = 1.2%, p = 0.0002) predicted 3-month ECL. Cataract density was significant on univariate (p = 0.04) but not multivariate analysis. The other variables did not associate with ECL.

CONCLUSIONS

Older age may amplify ECL due to increased endothelial cell fragility. EPT may promote ECL via cataract density-dependent and -independent mechanisms that should be considered in future phacoemulsification research aiming to reduce ECL. Our literature analysis showed that the average ECL for relatively unselected consecutively-sampled cohorts is 12%.

Parent-reported problems in children with Cerebral Visual Impairment: Improving the discriminative ability from ADHD and dyslexia using screening inventories

Daily problems of children with Cerebral Visual Impairment (CVI) are often misinterpreted as symptoms of behavioural disorders or learning disabilities instead of higher order visual function (HOVF) deficits. It is difficult to differentiate between various paediatric clinical groups based on daily manifestations. We used two CVI inventories (V-CVI-I, HVFQI) and an ADHD questionnaire (AVL) to compare parent-reported visual and behavioural problems of children with CVI, ADHD, dyslexia and neurotypical children (Age 6-15, Verbal Intelligence > 70). Our results show a higher percentage of parent-reported visual problems in children with CVI compared to all other groups, which was not affected by their visual acuity levels. On most HOVF categories, a higher percentage of parent-reported visual problems was also found in children with ADHD or dyslexia compared to neurotypical children. Children with ADHD had significantly more parent-reported behavioural problems, but more behavioural problems were reported by the parents of children with CVI compared to neurotypical children as well. Our findings complicate using the existing inventories for initial screening and referral of children with potential CVI. We propose a shortened screening list to improve the potential differentiation between CVI and ADHD or dyslexia based on parent-reported visual problems in everyday life.

Navigating the intersection of psychiatry and ophthalmology: A comprehensive review of depression and anxiety management in glaucoma patients

Glaucoma, a prevalent and debilitating eye disease, has long been associated with vision impairment and blindness. However, recent research has shed light on the often-underestimated psychological dimensions of this condition. Anxiety and depression, two pervasive psychiatric comorbidities, have been increasingly recognized among glaucoma patients. This comprehensive review aims to explore the intricate relationship between psychiatry and ophthalmology, in the context of managing depression and anxiety in glaucoma patients. By meticulously examining peer-reviewed literature, we synthesize current knowledge on the prevalence, risk factors, and underlying mechanisms of anxiety and depression in glaucoma. The evidence reveals that glaucoma patients face an elevated risk of experiencing these mood disorders. Factors such as progressive vision loss, complex medication regimens, and the fear of further visual deterioration contribute to their vulnerability. Moreover, we delve into the bidirectional relationship between glaucoma and mood disorders, shedding light on the complex interplay between ocular and emotional health. Our review investigates the implications of anxiety and depression on glaucoma management, including their potential impact on treatment adherence, disease progression, and overall quality of life. We also explore the neurobiological pathways linking glaucoma and mood disorders, providing a foundation for future research and potential therapeutic interventions. In conclusion, recognizing the psychological burden carried by glaucoma patients is essential for holistic and patient-centered care. This review underscores the pressing need for integrated approaches that bring together ophthalmological and psychiatric expertise to optimize the well-being of individuals facing the challenges of glaucoma. By addressing anxiety and depression in glaucoma care, healthcare providers can enhance the overall quality of life for these patients, ultimately leading to improved outcomes and a brighter future for those affected by this condition. This review offers valuable insight for healthcare practitioners and researchers, providing a concise overview of key topics and research in the field of managing depression and anxiety in glaucoma patients.

[Modified mini-SLET for treatment of complex cases in pterygium surgery]

BACKGROUND

The major problem associated with the benign but destructive growing pterygium is the high recurrence rate. A new surgical technique to lower recurrence rates is minor ipsilateral simple limbal epithelial transplantation (mini-SLET), where the regeneration potential of limbal stem cells is used in combination with amniotic membrane transplantation (AMT) for surgical reconstruction. The aim of this study is to assess the surgical outcome of the mini-SLET technique with tenonectomy, mitomycin C, and AMT as used in the authors' hospital.

MATERIALS AND METHODS

A total of 16 eyes from 15 patients undergoing mini-SLET after surgical pterygium removal with tenonectomy, mitomycin C, and AMT were analyzed retrospectively. Two different groups of pterygia were enrolled: group 1 included recurrent pterygia (n = 10) and group 2 comprised primary large pterygia such as double-head pterygia (n = 6). In addition to assessment of best corrected visual acuity and compete ophthalmological examination, preoperative slip-lamp examination with photo documentation served to calculate the corneal size of the pterygium head using VISUPAC software (Zeiss, Oberkochen, Germany). Postoperatively, best corrected visual acuity and slit-lamp examination were routinely evaluated. The surgical outcome was defined by the postoperatively achieved best corrected visual acuity, restoration of the ocular surface, recurrence rate, and rate of postoperative complications.

RESULTS

Median follow-up in all patients was 27 months; in groups 1 and 2 it was 30.7 and 25.3 months, respectively. No recurrence developed in 15 eyes (93.75%). Only one group 1 patient (6.25%) suffered a recurrent lesion after 10 months. Postoperatively, logMAR visual acuity did not change significantly. During follow-up, complications were limited to one case of early wound dehiscence.

CONCLUSION

Mini-SLET in combination with tenonectomy, mitomycin C, and AMT enables good surgical reconstruction of the ocular surface, and almost complete healing in the sense of restitutio ad integrum is possible. The results of the present study have shown the technique's effectiveness for recurrence prevention.

SNORD45A Affects Content of HIF-1α and Promotes Endothelial Angiogenic Function

To find out the differentially expressed small nucleolar RNAs (snoRNAs) in corneal neovascularization and their effect on angiogenesis. The rat model of corneal neovascularization induced by alkali burn was established, and the differentially expressed snoRNAs were sifted by high-throughput sequencing. Human genome homologs were screened and verified in cytopathological models. Polymerase chain reactions (PCRs) and Western blot assays were applied to detect mRNA and corresponding proteins affected by the differentially expressed snoRNA. In vitro, experiments were promoted to identify whether snoRNA affects endothelial cell migration and angiogenesis. Forty-seven differentially expressed snoRNAs were sifted from transparent cornea and neovascularization. According to sequencing and cytopathological model results, SNORD45A was selected for subsequent experiments. At mRNA and protein levels, SNORD45A affected the expression of HIF-1α. SNORD45A promoted endothelial angiogenesis through endothelial cell migration and tube formation regulation. The research suggested that SNORD45A partakes in the corneal neovascularization formation and can become one of the targets for corneal neovascularization therapy.

Dexamethasone Intracanalicular Insert for Clinically Significant Aqueous-Deficient Dry Eye: A Randomized Controlled Trial

PURPOSE

To evaluate a commercially available dexamethasone intracanalicular insert to treat dry eye.

DESIGN

Single-center, double-masked, randomized controlled trial.

PARTICIPANTS

Patients with clinically significant aqueous-deficient dry eye [combined ocular surface staining score ≥3 (0-12), corneal fluorescein staining ≥2 (0-6), and Schirmer's wetting <10 mm at 5 minutes in both eyes] with symptoms (dryness, eye discomfort, or visual fatigue, ≥30 [0-100]) despite treatment with at least one prescription drop and deemed candidate for topical steroid.

METHODS

Seventy-five adult patients were enrolled. A 1:1 randomization sequence was used to determine which eye of each patient would receive the treatment (dexamethasone 0.4 mg intracanalicular insert with 30-day elution time) or the sham (collagen plug). The fellow eye received the opposite treatment. Patients were masked to treatment assignment. Follow-up visits (at weeks 2, 4, and 6) were performed by a masked investigator.

MAIN OUTCOME MEASURES

Dry eye parameters and patient symptoms were used for efficacy and intraocular pressure (IOP) was used for safety assessment.

RESULTS

The severity of dry eye was comparable between the treatment arms (fellow eyes) at baseline. Eyes that received the dexamethasone insert had significantly less corneal staining at week 4 (mean difference [MD] -0.55, 95% confidence interval [CI] = -0.91, -0.19) and conjunctival staining at week 4 (MD -0.68, 95% CI = -1.05, -0.30) and week 6 (MD -0.34, 95% CI = -0.65, -0.02). Schirmer's wetting was comparable between the two treatment arms. Although the patients reported less dryness in eyes that received the insert at week 4 (MD -5.5, 95% CI = -11.4, 0.4), there were no statistically significant differences in any patient-reported symptoms. At week 4, dexamethasone-treated eyes were more likely to experience an IOP increase (by 5-10 mm Hg) (9 eyes vs. 1 eye; relative risk [RR] = 9.00, 95% CI = 1.14, 71.0; due to sparse events, the CI was very wide). All cases of increased IOP were managed with short-term topical beta blockers and subsided.

CONCLUSIONS

Dexamethasone intracanalicular insert may be considered a dropless dual treatment for clinically significant aqueous-deficient dry eye when topical steroid treatment is deemed appropriate.

Vogt-Koyanagi-Harada disease developed during chemotherapy for Hodgkin lymphoma: a case report

BACKGROUND

Ocular manifestations are known for non-Hodgkin lymphoma, but are rare for Hodgkin lymphoma. We report a case of Vogt-Koyanagi-Harada (VKH) disease presenting as serous retinal detachment and uveitis in both eyes in a child undergoing chemotherapy for Hodgkin lymphoma.

CASE PRESENTATION

The patient was a 7-year-old boy with stage IIB Hodgkin lymphoma (nodular lymphocyte predominant type) who was undergoing chemotherapy, including 2 cycles of the OEPA regimen and 1 cycle of the COPDAC regimen. Two days after the end of the COPDAC regimen, the patient complained of headache and of blurred and decreased vision in both eyes. On the basis of optic symptoms, such as uveitis and serous retinal detachment in both eyes, increased cell counts in cerebrospinal fluid, and positivity for human leukocyte antigen (HLA)-DR4 in peripheral blood cells, incomplete VKH disease was diagnosed. Intravenous treatment with high-dose prednisolone (60mg/m2/day) for 7 days improved both visual acuity and serous retinal detachment and enabled the remains of the COPDAC chemotherapy cycle to be administered. With prednisolone treatment, visual acuity improved from 20/500 to 20/20 in the right eye and from 20/63 to 20/25 in the left eye. Because multiple vitiligo lesions later appeared in the abdomen, complete VKH disease was finally diagnosed.

CONCLUSION

The onset of VKH disease occurred during chemotherapy for Hodgkin lymphoma. The patient was HLA-DR4-positive and might have had a predisposition to develop autoimmune diseases, including VKH disease. However, the anticancer drugs administered to this patient have not been reported to cause uveitis. Whether Hodgkin lymphoma triggered the development of VKH remains unclear. Early diagnosis of VKH disease and prompt treatment with high-dose prednisone enabled the patient to maintain good visual function despite chemotherapy for Hodgkin lymphoma.

Corneal biomechanics and diagnostics: a review

PURPOSE

Corneal biomechanics is an emerging field and the interest into physical and biological interrelations in the anterior part of the eye has significantly increased during the past years. There are many factors that determine corneal biomechanics such as hormonal fluctuations, hydration and environmental factors. Other factors that can affect the corneas are the age, the intraocular pressure and the central corneal thickness. The purpose of this review is to evaluate the factors affecting corneal biomechanics and the recent advancements in non-destructive, in vivo measurement techniques for early detection and improved management of corneal diseases.

METHODS

Until recently, corneal biomechanics could not be directly assessed in humans and were instead inferred from geometrical cornea analysis and ex vivo biomechanical testing. The current research has made strides in studying and creating non-destructive and contactless techniques to measure the biomechanical properties of the cornea in vivo.

RESULTS

Research has indicated that altered corneal biomechanics contribute to diseases such as keratoconus and glaucoma. The identification of pathological corneas through the new measurement techniques is imperative for preventing postoperative complications.

CONCLUSIONS

Identification of pathological corneas is crucial for the prevention of postoperative complications. Therefore, a better understanding of corneal biomechanics will lead to earlier diagnosis of ectatic disorders, improve current refractive surgeries and allow for a better postoperative treatment.

Management of symblepharon with Gore-tex as a novel treatment option for ocular chemical burns

PURPOSE

To assess the clinical outcomes of symblepharon release in patients with ocular surface chemical injury using Gore-Tex as a novel treatment option.

METHODS

This was a retrospective analysis of 23 eyes of 22 chemical injury patients done during a period of January 2014 to December 2021 at a tertiary eye care centre in South India. All patients underwent symblepharon lysis along with Gore-Tex application over the sclera with minimum 1 year follow up. The patients were assessed for demographic details, visual acuity, intraocular pressure, anterior and posterior segment details, photographic documentation, preoperative diagnosis, previous surgical details in recurrent cases, surgical procedures, final visual acuity, surgical outcomes, and complications. The clinical outcomes were assessed and outcomes were defined as success, partial success, or failure.

RESULTS

The median age was 17 years (IQR, 12-39 years). Among them 10 eyes with symblepharon had grade 3 length, 12 eyes grade 3 width and 12 eyes had grade 3 loss of palisades of Vogt. The success was achieved in 52.2% of the patients; partial success in 34.8% and 13.3% had failure. The mean duration of recurrence was 6.75 ± 3.6 months. Failure was noted in young patients with mean age 9.75years and with grade 3c symblepharon. There was no sight threatening complications noted.

CONCLUSION

The study showed very good results with Gore-Tex as a novel treatment option for chemical injury patient with symblepharon formation. It can be easily employed to prevent the symblepharon recurrence of various ocular surface disorders.

Scleral Fixated Secondary IOLs: An Outcomes Comparison Between the Yamane and Gore-Tex-Sutured Techniques

BACKGROUND AND OBJECTIVE

Among secondary intraocular lens (IOL) techniques, scleral fixated IOLs (SFIOLs) offer advantages in cases without capsular support. In this article, we compare outcomes between two types of Gore-Tex scleral sutured IOLs with the Yamane technique.

PATIENTS AND METHODS

This study was a retrospective chart review of patients who underwent SFIOL implantation.

RESULTS

Analysis revealed a statistically significant improvement in final postoperative visual acuity (VA) for sutured SFIOLs (P < 0.001, Envista (n = 29) 95% CI 0.47-1.04, Akreos (n = 23) 95% CI 0.32-0.81) with no statistical improvement in the Yamane group (P = 0.44, n = 15, 95% CI -0.33-0.71). Outcomes analysis revealed greater incidences of cystoid macular edema (CME) in the Yamane cohort (P < 0.05) and a higher rate of reoperations in the Akreos cohort (P < 0.02). All complications related to suture material (n = 4) and IOL decentration (n = 2) occurred in the sutured SFIOL group.

CONCLUSIONS

The sutureless Yamane technique offered fewer subsequent surgeries and suture-specific complications while revealing diminished VA improvement in long-term follow-up compared to the sutured SFIOLs. [Ophthalmic Surg Lasers Imaging Retina 2024;55:xx-xx.].

Functional Vision of Pseudophakic Children Attending a Pediatric Ophthalmology Clinic in Southwest Nigeria

PURPOSE

To determine the functional vision of pseudophakic children attending a child eye health tertiary facility in southwest Nigeria.

METHODS

A hospital-based descriptive study of pseudophakic children attending the Pediatric Ophthalmology outpatient clinic of a tertiary facility in southwest Nigeria was conducted between June and November 2021. Details of demography and clinical examination findings were obtained using a semi-structured questionnaire. Information about functional vision was obtained using the Pediatric Eye Questionnaire (PedEyeQ). Data obtained from the PedEyeQ were entered into a Rasch-calibrated PedEyeQ Excel response data sheet. Data analysis was done using Statistical Package for Social Sciences (SPSS) software version 22 (SPSS, Inc).

RESULTS

A total of 196 pseudophakic children were recruited. Their ages ranged from 2 to 16 years with a mean of 9.8 ± 3.4 years and there was a male-to-female ratio of 2.2:1. The median functional vision score of pseudophakic children across all age groups was 90.0. The functional vision scores were associated with the laterality of cataract, type of cataract, presence of comorbidities, visual acuity (distance and near) in the better eye, and number of surgeries.

CONCLUSIONS

The functional vision scores of pseudophakic children were low. Significant predictors of low functional vision scores include surgery for congenital cataract, low average family income, longer duration of time between surgery and recruitment into the study, and poorer best corrected visual acuity in the better eye. The routine assessment of functional vision should be considered an important aspect of pseudophakic children's eye care with a view toward optimizing psychological and social well-being. [J Pediatr Ophthalmol Strabismus. 2024;61(2):138-146.].

Ultrasound-Guided Injections for Treatment of Facial Paralysis Sequelae: A Randomized Study on Body Donors

BACKGROUND

Botulinum toxin injection is the accepted standard treatment for synkinesis and gustatory hyperlacrimation in patients with facial paralysis. However, poor injection accuracy can result in inconsistent treatment outcomes, variable treatment durations, and complications. Ultrasound guidance should increase injection accuracy in the facial region; however, this has not been proven.

METHODS

Twenty-six hemifaces of nonembalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated using several measures.

RESULTS

Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance ( P < 0.001). This was most pronounced in the lacrimal gland (62% versus 8%), depressor anguli oris (100% versus 46%), and mentalis (100% versus 54%) ( P < 0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance versus 29% without ( P < 0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance versus 83% without ( P < 0.01). Twenty-three percent of the landmark-guided depressor anguli oris injections stained the facial artery ( P = 0.22).

CONCLUSIONS

Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in the surrounding tissue compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in patients with facial paralysis.