Topical Antiseptics in Minimizing Ocular Surface Bacterial Load Before Ophthalmic Surgery: A Randomized Controlled Trial

PURPOSE

To investigate the reduction of the ocular surface bacterial load induced by 2 commercially available ophthalmic antiseptic formulations, povidone-iodine (PVI) 0.6% and chlorhexidine (CLX) 0.02%, before ocular surgery.

DESIGN

Randomized controlled trial.

METHODS

Seventy adult patients undergoing intraocular surgery (phacoemulsification) were randomized to receive in the index eye PVI (group A) 4 times a day for 3 days or CLX (group B) 4 times a day for 3 days before surgery. The untreated eye was used as control. A conjunctival swab was taken in both eyes before (T0) and after (T1) therapy. Microbial DNA was quantified with real-time polymerase chain reaction (PCR) analysis. The Mick algorithm was used to compare the abundance of each genus/genera against the distribution of abundances from the reference. At T1, patients filled a questionnaire to evaluate therapy-induced symptoms. Primary outcome was the reduction of bacterial DNA at T1 (microbial load), vs control arm, expressed as mean number of real-time PCR cycle times (CTs). Secondary outcomes were taxonomic composition, differential abundance, and therapy-induced ocular symptoms.

RESULTS

The T0-T1 difference in CT was significant in group B, but not in group A (mean [95% CI], 0.99 [0.33] vs 0.26 [0.15], P < .001, and 0.65 [0.3] vs 0.45 [0.41], P = .09, respectively). The taxonomic composition, alpha, and beta diversity remained consistent at all time points in both groups. The rate of patients reporting therapy-induced ocular symptoms and the mean discomfort grade were greater in group A than in group B (97% vs 26% and 4.97±2.48 vs 0.66±1.53, respectively).

CONCLUSIONS

Compared with PVI 0.6%, CLX 0.02% induced a greater reduction of ocular surface bacterial load, with no significant alterations of the taxonomic composition. Moreover, CLX was better tolerated than PVI.

Quality assurance in corneal transplants: Donor cornea assessment and oversight

The cornea is the most frequently transplanted human tissue, and corneal transplantation represents the most successful allogeneic transplant worldwide. In order to obtain good surgical outcome and visual rehabilitation and to ensure the safety of the recipient, accurate screening of donors and donor tissues is necessary throughout the process. This mitigates the risks of transmission to the recipient, including infectious diseases and environmental contaminants, and ensures high optical and functional quality of the tissues. The process can be divided into 3 stages: (1) donor evaluation and selection before tissue harvest performed by the retrieval team, (2) tissue analysis during the storage phase conducted by the eye bank technicians after the retrieval, and, (3) tissue quality checks undertaken by the surgeons in the operating room before transplantation. Although process improvements over the years have greatly enhanced safety, quality, and outcome of the corneal transplants, a lack of standardization between centers during certain phases of the process still remains, and may impact on the quality and number of transplanted corneas. Here we detail the donor screening process for the retrieval teams, eye bank operators. and ophthalmic surgeons and examine the limitations associated with each of these stages.

Antimicrobials and antiseptics: Lowering effect on ocular surface bacterial flora - A systematic review

Topical antimicrobials and antiseptics are used perioperatively to reduce the ocular surface bacteria flora (OSBF) that are involved in the development of post-operative infectious complications. However, their effectiveness is still a controversial topic. This systematic review, performed according to the PRISMA guidelines and registered in PROSPERO, aims to provide an overview of the efficacy of the agents currently used in peri-cataract surgery and -intravitreal injections (IVI) in lowering the OSBF. Although effective in lowering OSBF, perioperative topical antimicrobials are associated with the risk of resistance development, with no obvious additional benefit compared with topical antisepsis. Conversely, the effectiveness of topical antiseptics before cataract surgery and IVI is strongly supported. Based on the available evidence, perioperative antimicrobials are not recommended, whereas the perioperative use of antiseptics is strongly recommended as prophylactic treatment for lowering the infection due to OSBF. Post-operative antimicrobials may be considered in eyes at higher risk for infection.

Double trouble in DMEK surgery: Learning experience and review of the literature

PURPOSE

To report a challenging Descemet Membrane Endothelial Keratoplasty (DMEK) case, complicated by intraoperative aqueous misdirection and spontaneous anterior chamber fibrin reaction.

METHODS

A 70-year-old female affected by corneal edema due to Fuchs endothelial dystrophy underwent a triple procedure (cataract extraction - IOL implantation - DMEK surgery) in her left eye. This report illustrates the management of the intraoperative complications of aqueous misdirection syndrome and anterior chamber fibrin reaction.

RESULTS

Despite the optimal management of the posterior pressure and the thorough removal of the fibrinous reaction during the case, the DMEK graft was not completely unfolded and centred at the end of the surgical procedure. Nonetheless, the patient showed good long-term anatomical and functional recovery: at the last follow-up (2 years after surgery), central corneal thickness was 526 µm with a best corrected visual acuity of 20/25 and an endothelial cell density of 1112 cell/mm2.

CONCLUSION

Early recognition and prompt management of intraoperative aqueous misdirection syndrome and anterior chamber fibrin reaction during DMEK surgery is essential to ensure good functional and anatomical outcomes.

Cancer stem-like cells in uveal melanoma: Novel insights and therapeutic implications

Uveal melanoma (UM) is the most common primary ocular tumor in the adult population. Even though these primary tumors are successfully treated in 90% of cases, almost 50% of patients ultimately develop metastasis, mainly in the liver, via hematological dissemination, with a median survival spanning from 6 to 12 months after diagnosis. In this context, chemotherapy regimens and molecular targeted therapies have demonstrated poor response rates and failed to improve survival. Among the multiple reasons for therapy failure, the presence of cancer stem-like cells (CSCs) represents the main cause of resistance to anticancer therapies. In the last few years, the existence of CSCs in UM has been demonstrated both in preclinical and clinical studies, and new molecular pathways and mechanisms have been described for this subpopulation of UM cells. Here, we will discuss the state of the art of CSC biology and their potential exploitation as therapeutic target in UM.

Open-source, 3D printable IOL holder for detailed, smartphone-based anterior segment photography

Smartphones are increasingly relevant resources in medical practice as they are ubiquitous and reasonably cheap. Among the advantages of using smartphones in medical practise, there is the possibility of obtaining reproducible photographic documentation of various conditions. This is particularly true in the ophthalmic field, where anterior segment color photography plays a significant role in the diagnosis and the management of ocular surface diseases. Here we propose an original design for an open-source smartphone accessory for taking and sharing high-definition photographs of the anterior segment. It can be easily reproduced via 3D printing, and it only needs to be integrated with an intraocular lens (IOL), widely available to the majority of ophthalmologists. Compared to other solutions described previously, it allows a precise and reproducible placement of the IOL on the smartphone camera, avoiding manual positioning that could result tricky and time-consuming. The IOL holder is cheap, scalable, portable and it can be quickly assembled and disassembled, without permanently modifying the smartphone camera.

Comparative Analysis of Tomographic Indicators Forecasting Decompensation in Fuchs Endothelial Corneal Dystrophy

PURPOSE

To compare the performance of 3 commercially available tomographers (the Pentacam Scheimpflug camera, the swept-source optical coherence tomography Casia, and the blue light slit-scanning tomographer Precisio) in the identification of patterns associated with Fuchs endothelial corneal dystrophy (FECD) decompensation.

METHODS

This was a clinic-based cross-sectional imaging study. Pachymetry maps and posterior surface elevation maps were acquired with the 3 devices from 61 eyes affected by FECD. The maps were graded according to the evidence of tomographic patterns predictive of FECD decompensation (loss of parallel isopachs, displacement of the thinnest point, and focal posterior depression) by 2 blind cornea specialists.

RESULTS

The loss of parallel isopachs was significantly less frequently evident in Pentacam pachymetry maps [8%, 95% confidence interval (CI) (3%, 18%)] compared with both the Casia [31%, 95% CI (20%, 44%), P = 0.01] and Precisio devices [24%, 95% CI (15%, 37%), P = 0.05]. The displacement of the thinnest point was graded as most evident in a significantly higher proportion of Precisio pachymetry maps [43%, 95% CI (31%, 55%)] compared with both the Pentacam [13%, 95% CI (6%, 24%), P = 0.001] and Casia devices [21%, 95% CI (12%, 33%), P = 0.03]. There were no significant differences in the identification of focal posterior depression on posterior elevation maps across the 3 devices.

CONCLUSIONS

Identification of patterns predictive of FECD prognosis on pachymetry and posterior elevation maps is possible with different devices. However, their evidence varies across tomographers, and the results from different devices are not interchangeable.

Ocular phenotype and therapeutic interventions in keratitis-ichthyosis-deafness (KID) syndrome

BACKGROUND

To report ocular manifestations, clinical course, and therapeutic management of patients with molecular genetically confirmed keratitis-ichthyosis-deafness syndrome.

METHODS

Four patients, aged 19 to 46, with keratitis-ichthyosis-deafness syndrome from across the UK were recruited for a general and ocular examination and GJB2 (Cx26) mutational analysis. The ocular examination included best-corrected visual acuity, slit-lamp bio-microscopy, and ocular surface assessment. Mutational analysis of the coding region of GJB2 (Cx26) was performed by bidirectional Sanger sequencing.

RESULTS

All four individuals had the characteristic systemic features of keratitis-ichthyosis-deafness syndrome. Each patient was found to have a missense mutation, resulting in the substitution of aspartic acid with asparagine at codon 50 (p.D50N). Main ophthalmic features were vascularizing keratopathy, ocular surface disease, hyperkeratotic lid lesions, recurrent epithelial defects, and corneal stromal scarring. One patient had multiple surgical procedures, including superficial keratectomies and lamellar keratoplasty, which failed to prevent severe visual loss. In contrast, oral therapy with ketoconazole stabilized the corneal and skin disease in two other patients with keratitis-ichthyosis-deafness syndrome. The patient who underwent intracorneal bevacizumab injection showed a marked reduction in corneal vascularization following a single application.

CONCLUSIONS

Keratitis-ichthyosis-deafness syndrome is a rare ectodermal dysplasia caused by heterozygous mutations in GJB2 (Cx26) with a severe, progressive vascularizing keratopathy. Oral ketoconazole therapy may offer benefit in stabilizing the corneal and skin disease.

Combined or sequential DMEK in cases of cataract and Fuchs endothelial corneal dystrophy-A systematic review and meta-analysis

To compare the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed after phacoemulsification and intraocular lens (IOL) implantation (sequential DMEK) and DMEK combined with phacoemulsification and IOL implantation (combined DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and cataract. Systematic literature review and meta-analysis performed according to the PRISMA guidelines and registered in PROSPERO. Literature searches were conducted in Medline and Scopus. Comparative studies reporting sequential DMEK and combined DMEK in FECD patients were included. The main outcome measure of the study was the corrected distance visual acuity (CDVA) improvement. Secondary outcomes were postoperative endothelial cell density (ECD), rebubbling rate and primary graft failure rate. Bias risk was assessed and a quality appraisal of the body of evidence was completed using the Cochrane Robin-I tool. A total of 667 eyes (5 studies) were included in this review, 292 eyes (43.77%) underwent a combined DMEK, while 375 (56.22%) eyes underwent a sequential DMEK surgery. We found no evidence of a difference between the two groups (mean difference, 95% CI) regarding: (1) CDVA improvement (-0.06; -0.14, 0.03 LogMAR; 3 studies, I2 : 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm2 ; 4 studies, I2 : 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I2 : 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I2 : 0%; p = 0.86). Of all the 5 non-randomized studies, all (100%) were graded as low quality. The overall quality of the analysed studies was low. Randomized controlled trials are needed to confirm no difference or superiority of one approach in terms of CDVA, endothelial cell count and postoperative complication rate between the two arms.

Reporting standard for describing first responder systems, smartphone alerting systems, and AED networks

Standardized reporting of data is crucial for out-of-hospital cardiac arrest (OHCA) research. While the implementation of first responder systems dispatching volunteers to OHCA is encouraged, there is currently no uniform reporting standard for describing these systems. A steering committee established a literature search to identify experts in smartphone alerting systems. These international experts were invited to a conference held in Hinterzarten, Germany, with 40 researchers from 13 countries in attendance. Prior to the conference, participants submitted proposals for parameters to be included in the reporting standard. The conference comprised five workshops covering different aspects of smartphone alerting systems. Proposed parameters were discussed, clarified, and consensus was achieved using the Nominal Group Technique. Participants voted in a modified Delphi approach on including each category as a core or supplementary element in the reporting standard. Results were presented, and a writing group developed definitions for all categories and items, which were sent to participants for revision and final voting using LimeSurvey web-based software. The resulting reporting standard consists of 68 core items and 21 supplementary items grouped into five topics (first responder system, first responder network, technology/algorithm/strategies, reporting data, and automated external defibrillators (AED)). This proposed reporting standard generated by an expert opinion group fills the gap in describing first responder systems. Its adoption in future research will facilitate comparison of systems and research outcomes, enhancing the transfer of scientific findings to clinical practice.

Role of Direct Supervision in the Learning Curve of Descemet Membrane Endothelial Keratoplasty Surgery

PURPOSE

The aim of this study was to compare complication rates of Descemet membrane endothelial keratoplasty (DMEK) performed by directly supervised and nondirectly supervised corneal fellows.

METHODS

This study was a retrospective, comparative case series of DMEK surgeries performed by novice surgeons (less than 15 DMEK cases) with or without direct direct expert supervision. Patients who underwent surgery for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy with a minimum follow-up of 12 weeks were included. Data on patients' demographics, surgical details, surgeon level, intraoperative and postoperative complications, and rate of rebubbling were collected.

RESULTS

In this study, 41 nondirectly supervised and 48 directly supervised DMEK surgeries were included. At 6 months, 67.4% of eyes achieved a best-corrected visual acuity of ≤0.3 logMAR with no significant difference between groups ( P = 0.95). Intraoperative complications occurred in 22% of cases in the nondirect supervision group and 4.2% in the direct supervision group ( P = 0.02). Postoperative complications occurred in 9.8% of cases in the nondirect supervision group and 6.2% of cases in the direct supervision group ( P = 0.7). The rebubbling rate was comparable in the 2 groups (34.1% vs. 33.3%, P = 1.0). Five cases (12.2%), all from the nondirect supervision group, required secondary keratoplasty ( P = 0.02). The overall complication rate was significantly higher in the nondirect supervision group (31.7% vs. 10.4%, P = 0.03).

CONCLUSIONS

Functional success can be achieved in directly supervised or nondirectly supervised DMEK surgery. However, nondirectly supervised DMEK surgery may associate with higher rates of complications.

Incidence and management of early postoperative complications in lamellar corneal transplantation

PURPOSE

To provide a comprehensive review of the incidence, risk factors, and management of early complications after deep anterior lamellar keratoplasty (DALK), Descemet stripping automated keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK).

METHODS

A literature review of complications, that can occur from the time of the transplant up to 1 month after the transplant procedure, was conducted. Case reports and case series were included in the review.

RESULTS

Complications in the earliest postoperative days following anterior and posterior lamellar keratoplasty have shown to affect graft survival. These complications include, but are not limited to, double anterior chamber, sclerokeratitis endothelial graft detachment, acute glaucoma, fluid misdirection syndrome, donor-transmitted and recurrent infection, and Uretts-Zavalia syndrome.

CONCLUSION

It is essential for surgeons and clinicians to not only be aware of these complications but also know how to manage them to minimize their impact on long-term transplant survival and visual outcomes.

DMEK surgical training: An instructional guide on various wet-lab methods

Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of the Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques, such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection, and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be more challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool, especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and nonhuman models with instructional videos. This article should eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques.

Preoperative surgeon evaluation of corneal endothelial status: the Viability Control of Human Endothelial Cells before Keratoplasty (V-CHECK) study protocol

INTRODUCTION

The success of keratoplasty strongly depends on the health status of the transplanted endothelial cells. Donor corneal tissues are routinely screened for endothelial damage before shipment; however, surgical teams have currently no means of assessing the overall viability of corneal endothelium immediately prior to transplantation. The aim of this study is to validate a preoperative method of evaluating the endothelial health of donor corneal tissues, to assess the proportion of tissues deemed suitable for transplantation by the surgeons and to prospectively record the clinical outcomes of a cohort of patients undergoing keratoplasty in relation to preoperatively defined endothelial viability.

METHODS AND ANALYSIS

In this multicentre cohort study, consecutive patients undergoing keratoplasty (perforating keratoplasty, Descemet stripping automated endothelial keratoplasty (DSAEK), ultra-thin DSAEK (UT-DSAEK) or Descemet membrane endothelial keratoplasty) will be enrolled and followed-up for 1 year. Before transplantation, the endothelial viability of the donor corneal tissue will be evaluated preoperatively through trypan blue staining and custom image analysis to estimate the overall percentage of trypan blue-positive areas (TBPAs), a proxy of endothelial damage. Functional and structural outcomes at the end of the follow-up will be correlated with preoperatively assessed TBPA values.

ETHICS AND DISSEMINATION

The protocol will be reviewed by the ethical committees of participating centres, with the sponsor centre issuing the final definitive approval. The results will be disseminated on ClinicalTrials.gov, at national and international conferences, by partner patient groups and in open access, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05847387.

Predictability of the vault after implantable collamer lens implantation using OCT and artificial intelligence in White patient eyes

PURPOSE

To compare the predicted vault using machine learning with the achieved vault using the online manufacturer's nomogram in patients undergoing posterior chamber implantation with an implantable collamer lens (ICL).

SETTING

Centro Oculistico Bresciano, Brescia, Italy, and I.R.C.C.S.-Bietti Foundation, Rome, Italy.

DESIGN

Retrospective multicenter comparison study.

METHODS

561 eyes from 300 consecutive patients who underwent ICL placement surgery were included in this study. All preoperative and postoperative measurements were obtained by anterior segment optical coherence tomography (AS-OCT; MS-39). The actual vault was quantitatively measured and compared with the predicted vault using machine learning of AS-OCT metrics.

RESULTS

A strong correlation between model predictions and achieved vaulting was detected by random forest regression (RF; R2 = 0.36), extra tree regression (ET; R2 = 0.50), and extreme gradient boosting regression ( R2 = 0.39). Conversely, a high residual difference was observed between achieved vaulting values and those predicted by the multilinear regression ( R2 = 0.33) and ridge regression ( R2 = 0.33). ET and RF regressions showed significantly lower mean absolute errors and higher percentages of eyes within ±250 μm of the intended ICL vault compared with the conventional nomogram (94%, 90%, and 72%, respectively; P < .001). ET classifiers achieved an accuracy (percentage of vault in the range of 250 to 750 μm) of up to 98%.

CONCLUSIONS

Machine learning of preoperative AS-OCT metrics achieved excellent predictability of ICL vault and size, which was significantly higher than the accuracy of the online manufacturer's nomogram, providing the surgeon with a valuable aid for predicting the ICL vault.

FGF-trapping hampers cancer stem-like cells in uveal melanoma

BACKGROUND

Cancer stem-like cells (CSCs) are a subpopulation of tumor cells responsible for tumor initiation, metastasis, chemoresistance, and relapse. Recently, CSCs have been identified in Uveal Melanoma (UM), which represents the most common primary tumor of the eye. UM is highly resistant to systemic chemotherapy and effective therapies aimed at improving overall survival of patients are eagerly required.

METHODS

Herein, taking advantage from a pan Fibroblast Growth Factor (FGF)-trap molecule, we singled out and analyzed a UM-CSC subset with marked stem-like properties. A hierarchical clustering of gene expression data publicly available on The Cancer Genome Atlas (TCGA) was performed to identify patients' clusters.

RESULTS

By disrupting the FGF/FGF receptor (FGFR)-mediated signaling, we unmasked an FGF-sensitive UM population characterized by increased expression of numerous stemness-related transcription factors, enhanced aldehyde dehydrogenase (ALDH) activity, and tumor-sphere formation capacity. Moreover, FGF inhibition deeply affected UM-CSC survival in vivo in a chorioallantoic membrane (CAM) tumor graft assay, resulting in the reduction of tumor growth. At clinical level, hierarchical clustering of TCGA gene expression data revealed a strong correlation between FGFs/FGFRs and stemness-related genes, allowing the identification of three distinct clusters characterized by different clinical outcomes.

CONCLUSIONS

Our findings support the evidence that the FGF/FGFR axis represents a master regulator of cancer stemness in primary UM tumors and point to anti-FGF treatments as a novel therapeutic strategy to hit the CSC component in UM.

A goat eye, wet lab model for training in Descemet membrane endothelial keratoplasty

Here we describe a new, non-human, ex-vivo model (goat eye model) for training surgeons in DMEK surgeons. In a wet lab setting, goat eyes were used to obtain a pseudo-DMEK graft of 8 mm from the goat lens capsule that was injected into another goat eye with the same maneuvers described for human DMEK. The DMEK pseudo-graft can be easily prepared, stained, loaded, injected, and unfolded into the goat eye model reproducing the similar maneuvers used for DMEK in a human eye, except for the descemetorhexis, which cannot be performed. The pseudo-DMEK graft behaves similar to human DMEK graft and useful for surgeons to experience and understand steps of DMEK early in learning curve. The concept of a non-human ex-vivo eye model is simple and reproducible and obviates the need for human tissue and the issues of poor visibility in stored corneal tissue.

Deep Learning Using Preoperative AS-OCT Predicts Graft Detachment in DMEK

Purpose

To evaluate a novel deep learning algorithm to distinguish between eyes that may or may not have a graft detachment based on pre-Descemet membrane endothelial keratoplasty (DMEK) anterior segment optical coherence tomography (AS-OCT) images.

Methods

Retrospective cohort study. A multiple-instance learning artificial intelligence (MIL-AI) model using a ResNet-101 backbone was designed. AS-OCT images were split into training and testing sets. The MIL-AI model was trained and validated on the training set. Model performance and heatmaps were calculated from the testing set. Classification performance metrics included F1 score (harmonic mean of recall and precision), specificity, sensitivity, and area under curve (AUC). Finally, MIL-AI performance was compared to manual classification by an experienced ophthalmologist.

Results

In total, 9466 images of 74 eyes (128 images per eye) were included in the study. Images from 50 eyes were used to train and validate the MIL-AI system, while the remaining 24 eyes were used as the test set to determine its performance and generate heatmaps for visualization. The performance metrics on the test set (95% confidence interval) were as follows: F1 score, 0.77 (0.57-0.91); precision, 0.67 (0.44-0.88); specificity, 0.45 (0.15-0.75); sensitivity, 0.92 (0.73-1.00); and AUC, 0.63 (0.52-0.86). MIL-AI performance was more sensitive (92% vs. 31%) but less specific (45% vs. 64%) than the ophthalmologist's performance.

Conclusions

The MIL-AI predicts with high sensitivity the eyes that may have post-DMEK graft detachment requiring rebubbling. Larger-scale clinical trials are warranted to validate the model.

Translational Relevance

MIL-AI models represent an opportunity for implementation in routine DMEK suitability screening.

Intraoperative OCT for Lamellar Corneal Surgery: A User Guide

Intraoperative OCT is an innovative and promising technology which allows anterior and posterior segment ocular surgeons to obtain a near-histologic cross-sectional and tomographic image of the tissues. Intraoperative OCT has several applications in ocular surgery which are particularly interesting in the context of corneal transplantation. Indeed, iOCT images provide a direct and meticulous visualization of the anatomy, which could guide surgical decisions. In particular, during both big-bubble and manual DALK, the visualization of the relationship between the corneal layers and instruments allows the surgeon to obtain a more desirable depth of the trephination, thus achieving more type 1 bubbles, better regularity of the plane, and a reduced risk of DM perforation. During EK procedures, iOCT supplies information about proper descemetorhexis, graft orientation, and interface quality in order to optimize the postoperative adhesion and reduce the need for re-bubbling. Finally, mushroom PK, a challenging technique for many surgeons, can be aided through the use of iOCT since it guides the correct apposition of the lamellae and their centration. The technology of iOCT is still evolving: a larger field of view could allow for the visualization of all surgical fields, and automated tracking and iOCT autofocusing guarantee the continued centration of the image.

Selective laser capsulotomy complications: Management and prevention

PURPOSE

To report how to manage and prevent the incomplete laser cut and following uncut tags of anterior capsular lens, performed using the selective laser capsulotomy.

METHODS

We describe three possible approaches: peeling the anterior capsulotomy disc with forceps, breaking the tags using the cystotomy needle tip, or cutting them using a 23-G vitrectomy scissors.

RESULTS

Using the 23-G vitrectomy scissors resulted in no complication. Peeling the anterior capsulotomy using the forceps instead caused zonular stress with subsequent risks of zonular dialysis, whereas using the cystotomy needle tip resulted in irregular capsulotomy rim and weakness all along the capsulotomy edge where micro tears caused a tear during the rest of cataract surgery.

CONCLUSION

Incomplete laser cut and subsequent discontinuous capsulotomy results in the presence of multiple tags which create strong adherence between the central capsulotomy disc and the peripheral capsule. Key steps of the procedure to prevent an incomplete laser cut, which are the anterior lens capsule staining and laser beam focusing, and how to correctly manage them, which may shorten the learning curve and enhance the outcomes.

DMEK graft: One size does not fit all

Descemet membrane endothelial keratoplasty (DMEK) is a popular procedure for the treatment of corneal endothelial diseases mainly targeting Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). Although DMEK has multiple advantages, it is challenging in terms of graft preparation and delivery. One of the crucial factors of DMEK graft preparation is determining the size of the graft. Evaluating risks and benefits of transplanting larger or smaller grafts compared with the descemetorhexis performed following a standard DMEK procedure thus becomes important. Advanced techniques like pre-loaded DMEK requires pre-selection of graft diameter without physical examination of the eye making it more challenging. Therefore, recognizing the benefits of graft size and the number of transplanted endothelial cells becomes essential. Smaller DMEK grafts have been preferred and accepted for grafting. Larger diameter grafts have advantages but can be challenging due to higher detachment rates. We thus aim to review the challenges of preparing and delivering DMEK tissues with small or large diameter based on selected descemetorhexis area, discuss the outcomes based on different graft sizes, highlight related complications and suggest which cases may benefit from adopting smaller or larger graft size.

Neurovisual profile in children affected by Angelman syndrome

BACKGROUND

Angelman syndrome (AS) is a rare neurogenetic disorder caused by altered expression of the maternal copy of the UBE3A gene. Together with motor, cognitive, and speech impairment, ophthalmological findings including strabismus, and ocular fundus hypopigmentation characterize the clinical phenotype. The aim of this study was to detail the neurovisual profile of children affected by AS and to explore any possible genotype-phenotype correlations.

METHODS

Thirty-seven children (23 females, mean age 102.8 ± 54.4 months, age range 22 to 251 months) with molecular confirmed diagnosis of AS were enrolled in the study. All underwent a comprehensive video-recorded neurovisual evaluation including the assessment of ophthalmological aspects, oculomotor functions, and basic visual abilities.

RESULTS

All children had visual impairments mainly characterized by refractive errors, ocular fundus changes, strabismus, discontinuous/jerky smooth pursuit and altered saccadic movements, and/or reduced visual acuity. Comparing the neurovisual profiles between the deletion and non-deletion genetic subgroups, we found a significant statistical correlation between genotype and ocular fundus hypopigmentation (p = 0.03), discontinuous smooth pursuit (p < 0.05), and contrast sensitivity abnormalities (p < 0.01) being more frequent in the deletion subgroup.

CONCLUSIONS

Subjects affected by AS present a wide spectrum of neurovisual impairments that lead to a clinical profile consistent with cerebral visual impairment (CVI). Moreover, subjects with a chromosome deletion show a more severe visual phenotype with respect to ocular fundus changes, smooth pursuit movements, and contrast sensitivity. Early detection of these impaired visual functions may help promote the introduction of neurovisual habilitative programs which can improve children's visual, neuromotor, and cognitive outcomes.

Surgical goniolens for tag identification and removal in DMEK surgery

INTRODUCTION

We describe a novel technique for identifying endothelial Descemet membrane (DM) tags remaining after descemetorhexis in patients undergoing Descemet membrane endothelial keratoplasty (DMEK) surgery.

METHODS

A surgical goniolens is applied to the corneal surface after descemetorhexis in order to visualize the peripheral inner corneal layer at 360° and identify endothelial-DM tags.

RESULTS

A detailed visualization of the peripheral inner corneal layer is possible using goniolens, without using any staining in the anterior chamber.

CONCLUSION

The technique may be used to screen the posterior corneal surface for any retained endothelial-DM tags. It may to lower the risk of remaining tags and indirectly lower the incidence of DMEK graft detachment.

Andrological effects of SARS-Cov-2 infection: a systematic review and meta-analysis

PURPOSE

The short- and long-term andrological effects of coronavirus disease 2019 (COVID-19) have not been clarified. Our aim is to evaluate the available evidence regarding possible andrological consequences of COVID-19 either on seminal or hormonal parameters. The safety of the COVID-19 vaccines in terms of sperm quality was also investigated.

METHODS

All prospective and retrospective observational studies reporting information on severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) mRNA semen and male genitalia tract detection (n = 19), as well as those reporting data on semen analysis (n = 5) and hormonal parameters (n = 11) in infected/recovered patients without any arbitrary restriction were included.

RESULTS

Out of 204 retrieved articles, 35 were considered, including 2092 patients and 1138 controls with a mean age of 44.1 ± 12.6 years, and mean follow-up 24.3 ± 18.9 days. SARS-CoV-2 mRNA can be localized in male genitalia tracts during the acute phase of the disease. COVID-19 can result in short-term impaired sperm and T production. Available data cannot clarify long-term andrological effects. Low T observed in the acute phase of the disease is associated with an increased risk of being admitted to the Intensive Care Unit or death. The two available studies showed that the use of mRNA COVID-19 vaccines does not affect sperm quality.

CONCLUSIONS

The results of our analysis clearly suggest that each patient recovering from COVID-19 should be monitored to rule out sperm and T abnormalities. The specific contribution of reduced T levels during the acute phase of the infection needs to be better clarified.

Therapeutic Hyper-CL soft contact lens in Sjögren's syndrome

Purpose

Observations

Conclusions and importance

Artificial iris implantation in congenital aniridia A systematic review

Congenital aniridia is a rare, panocular disorder with a main phenotypic characteristic of a partial or complete absence of the iris existing alongside other ocular morbidities such as cataract, keratopathy, optic nerve and foveal hypoplasia, and nystagmus. The iris abnormality, however, often leads to symptoms such as photophobia, glare, and decreased visual acuity, as well as cosmetic dissatisfaction. Current management options for the iris deficit include colored iris contact lenses, corneal tattooing, and tinted contact lenses. Symptoms arising from small iris defects can be resolved with surgical management using micro-tying suture techniques such as McCannel or Siepser. Currently, larger iris defects can be treated with artificial iris implants. New prosthetic options range from colored intraocular lenses to flexible custom-made silicone iris implants. With a range of therapeutic options available and given the challenges of multiple comorbidities in aniridia, we evaluate the literature relating to the use of artificial iris implants in congenital aniridia, with a focus on the different surgical implantation techniques, the clinical outcomes achieved, complications occurred, and risk of bias of the studies included.

What empiric treatment should be given for suspected bacterial keratitis in Northern Italy?

There is a lack of epidemiological studies reporting bacteria profiles, susceptibility, and suggested empiric (first line) treatment in Northern Italy. Our internal audit of corneal scraping for microbial keratitis at University of Brescia reports 116 bacterial strains isolated between January 1, 2013, and December 31, 2020. All cases had at least an epithelial defect of 1 mm in diameter. 36.2% (42) were Gram-positive, while 63.7% (74) Gram negative. In our results Gram-negatives are sensitive to ciprofloxacin in 94.5% and Pseudomonas in 95%. Grampositives are sensitive to teicoplanin in 91,1%. Those data may help to establish empiric treatment in case of bacterial keratitis.

COVID-19 AdenoviralVector Vaccine and Central Retinal Vein Occlusion

PURPOSE

The purpose of this article is to report a case of sudden onset ischemic retinal central vein occlusion after a second dose of COVID-19 adenoviral vector vaccine.

CASE REPORT/OBSERVATIONS

A 54-year-old woman with systemic arterial hypertension developed ischemic central retinal vein occlusion in her right eye on day 2 after the second dose of COVID-19 adenoviral vector vaccine ChAdOx1 nCoV-19/ AZD1222, Oxford-AstraZeneca.

CONCLUSION

Adenoviral vector vaccine promotes both cellular and humoral immune responses, increasing the level of inflammatory cytokines. These cytokines are the same implied in the possible pathogenesis of central retinal vein occlusion. Subsequently, we recommend informing patients at risk of possible ocular adverse events, which require urgent evaluation.

Visual and Refractive Outcomes Following Laser Blended Vision With Non-linear Aspheric Micro-anisometropia (PRESBYOND) in Myopic and Hyperopic Patients

PURPOSE

To report 6-month visual and refractive outcomes following PRESBYOND Laser Blended Vision (Carl Zeiss Meditec) treatment using non-linear aspheric micro-anisometropia laser in situ keratomileusis (LASIK) for the correction of myopic and hyperopic presbyopia.

METHODS

A retrospective, non-comparative study of 139 consecutive patients with a mean age of 53.13 ± 5.84 years (range: 42 to 70 years) treated with LASIK-induced micro-anisometropia using the MEL 90 excimer laser and VisuMax femtosecond laser (both Carl Zeiss Meditec). The target refraction was plano for distance eyes (dominant eye) and between -0.50 and -1.50 diopters (D) for near eyes. Patients were observed for 6 months.

RESULTS

A total of 278 eyes (78 myopic and 200 hyperopic) from 139 patients completed the study. Mean preoperative spherical equivalent (SE) was -3.40 ± 1.83 D (range: -0.50 to -8.25 D) for myopic eyes and +1.61 ± 0.98 D (range: -1.25 to +4.63 D) for hyperopic eyes. Mean postoperative SE refraction of distance eyes was +0.20 ± 0.35 D (range: -0.38 to +1.00 D) and -0.14 ± 0.42 D (range: -1.38 to +0.88 D) for myopic and hyperopic eyes, respectively. Mean postoperative SE refraction of near eyes was -0.90 ± 0.44 D (range: -0.13 to -2.25 D) and -1.21 ± 0.48 D (range: -0.13 to -2.25 D) for myopic and hyperopic eyes, respectively. Mean binocular uncorrected near visual acuity was 0.70 ± 0.28 logMAR (range: 0.32 to 1.00 logMAR) and 0.79 ± 0.27 logMAR (range: 0.25 to 1.00 logMAR) for myopic and hyperopic eyes, respectively. Mean binocular uncorrected distance visual acuity was 1.19 ± 0.18 logMAR (range: 0.63 to 1.25 logMAR) and 1.14 ± 0.26 logMAR (range: 0.40 to 1.25 logMAR) for myopic and hyperopic eyes, respectively. Stereoacuity was better than 100 seconds of arc in 79% of myopic eyes and 85% of hyperopic eyes and all vision quality scores were greater than 90 of 100. No eyes lost two or more lines.

CONCLUSIONS

The non-linear aspheric micro-anisometropia protocol resulted in safe and effective visual outcomes in patients with both myopic and hyperopic presbyopia. [J Refract Surg. 2022;38(5):288-297.].

Age-Related Effects on the Spectrum of Cerebral Visual Impairment in Children With Cerebral Palsy

Background

Cerebral Visual Impairment (CVI) is a very common finding in children affected by Cerebral Palsy (CP). In this paper we studied the characteristics of CVI of a large group of children with CP and CVI, describing their neurovisual profiles according to three different age subgroups (subgroup 1: infants 6 months–2 years; subgroup 2: pre-school age 3–5 years; subgroup 3: school age ≥ 6 years).

Methods

We enrolled 180 subjects (104 males, mean age 66 ± 42.6 months; range 6–192 months) with CP and CVI for the study. We carried out a demographic and clinical data collection, neurological examination, developmental or cognitive assessment, and a video-recorded visual function assessment including an evaluation of ophthalmological characteristics, oculomotor functions, and basic visual functions. In school-aged children, we also performed an evaluation of their cognitive-visual profiles.

Results

There were signs of CVI in all the three subgroups. Subgroup 1 (62 children) and subgroup 2 (50 children) were different for fixation (p = 0.02), visual acuity (p = 0.03) and contrast sensitivity (p < 0.01), being more frequently impaired in younger children. Comparing subgroup 2 with subgroup 3 (68 children), the older children presented more frequently myopia (p = 0.02) while the younger ones esotropia (p = 0.02) and alteration in smooth pursuit (p = 0.03) and saccades (p < 0.01). Furthermore, fixation, smooth pursuit, visual acuity, contrast sensitivity and visual filed (p < 0.01) were more frequently impaired in younger children (subgroup 1) compared to the older ones. Multiple correspondence analysis (MCA) confirmed the different neurovisual profiles according to age: younger children with CP showed more signs of CVI compared to the older ones. 34 out of 68 children belonging to subgroup 3 underwent the cognitive visual evaluation; an impairment of cognitive visual skills was detected in 21 subjects.

Conclusion

Younger children with CP showed more signs of CVI compared to the older ones, likely for the physiological maturation of visual system and mechanisms of neuroplasticity. In this direction, we suggest an early neurovisual evaluation to detect any weak visual functions.

Update on Suture Techniques in Corneal Transplantation: A Systematic Review

Effective suturing remains key to achieving successful outcomes in corneal surgery, especially anterior lamellar keratoplasty and full thickness transplantation. Limitations in the technique may result in complications such as wound leak, infection, or high astigmatism post corneal graft. By using a systematic approach, this study reviews articles and conducts content analysis based on update 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria). The aim of this paper is to summarize the state of the art of corneal suturing techniques for every type of corneal transplant and patient age and also their outcomes regarding astigmatism and complications. Future developments for corneal transplantation will be also discussed. This is important because especially the young surgeon must have knowledge of the implications of every suture performed in order to achieve consistent and predictable post-operative outcomes and also be aware of all the possible complications.

Neurodevelopmental Profile in Children Affected by Ocular Albinism

AIM

The aim of this study was to detail the neurodevelopmental profile of subjects affected by ocular albinism (OA) and to collect data on GPR143 gene analysis.

DESIGN

The design of the study involves a retrospective longitudinal observational case series.

METHODS

We collected data on the neurodevelopmental profile of 13 children affected by OA from clinical annual assessments conducted for a period of 6 years after the first evaluation. We described visual profile, neuromotor development and neurological examination, cognitive profile, communication and language skills and behavioral characteristics. The GPR143 gene analysis was performed as well.

RESULTS

Children presented a variable combination of ocular and oculomotor disorders unchanged during the follow-up, a deficit in visual acuity and in contrast sensitivity that progressively improved. Abnormalities in pattern visual evoked potential were found. No deficits were detected at neurological examination and neuromotor development except for a mild impairment in hand-eye coordination observed in five cases. A language delay was observed in five cases, two of whom had also a developmental quotient delay at 2 years evolving to a borderline/deficit cognitive level at preschool age, difficulties in adaptive behavior and autistic-like features were found. Mutations in the GPR143 gene were identified in the two patients who presented the most severe clinical phenotype.

CONCLUSION

Children with OA may share, in addition to a variable combination of ocular signs and symptoms, a neurodevelopment impairment regarding mostly the cognitive, communicative, and social area, especially those with GPR143 mutation.

Lack of knowledge on acute stroke in children, adolescents and adults from public schools

Introduction

Stroke is an important cause of disability and death in adults worldwide. However, it is preventable in most cases. This community-based study investigated students' stroke knowledge, emergency medical services (EMS) activation, associated risk factors, warning signs and symptoms, and prior experience from different educational levels.

Methods

We conducted the survey with a structured questionnaire between March 2019 and December 2020.

Results

Students from the elementary school (n=1,187, ∼13 y.o., 14% with prior experience, 51% women), high school (n=806, ∼17 y.o., 13% with prior experience, 47% women) and University (n=1,961, ∼22 y.o., 9% with prior experience, 66% women) completed the survey. Among the students, the awareness of stroke general knowledge, associated risk factors, and warning signs and symptoms varied between 42–66%. When stimulated, less than 52% of the students associated stroke with hypercholesterolemia, smoking, diabetes, and hypertension. When stimulated, 62–65% of students recognised arm weakness, facial drooping, and speech difficulty; only fewer identified acute headache (43%). Interestingly, 67% knew the EMS phone number; 81% were willing to have stroke education included at school, and 75.2% found it essential and mandatory. Female, higher education and prior experience were associated with higher scores of stroke risk factors (OR: 1.28, 95% CI: 1.10–1.48; OR: 2.12, 95% CI:1.87–2.40; and OR: 1.46, 95% CI: 1.16–1.83; respectively), and signs and symptoms (OR: 2.22, 95% CI: 1.89–2.60; OR: 3.30, 95% CI: 2.81–3.87; and OR: 2.04, 95% CI: 1.58–2.63; respectively).

Conclusion

Being female, having prior experience, and a higher educational level increase the identification of associated risk factors and warning signs and symptoms. Stroke awareness should be emphasized among schoolchildren and adolescents.

Funding Acknowledgement

Type of funding sources: None.

SURGICAL OUTCOMES OF VITREOMACULAR TRACTION TREATED WITH FOVEAL-SPARING PEELING OF THE INTERNAL LIMITING MEMBRANE

PURPOSE

To compare sensitivity of the retina after complete internal limiting membrane (ILM) peeling versus foveal-sparing ILM peeling in vitrectomy for vitreomacular traction syndrome.

METHODS

This was a randomized, prospective, comparative study. Thirty-four eyes were randomized to undergo peeling with foveal sparing of the ILM (FS group) or complete peeling group. Foveal and perifoveal retinal sensitivity, visual acuity, and central macular thickness were the main outcome measures.

RESULTS

Parafoveal retinal sensitivity exhibited a significant improvement in both the FS and complete peeling groups (+2.43 ± 0.82 dB and +1.79 ± 0.86 dB, respectively; P = 0.037). Significant improvements were observed in both visual acuity and central macular thickness in both groups. No cases of epiretinal membrane recurrence were observed in the FS group.

CONCLUSION

Both the FS and complete peeling surgical techniques are safe and yielded good anatomical and functional results; however, a significant difference in favor of FS was found in relation to the best-corrected visual acuity and perifoveal retinal sensitivity. Preservation of the foveal ILM disc allowed the anatomical restoration of the foveal architecture in most vitreomacular traction syndrome cases without signs of stiffening or ILM fibrosis over a follow-up period of 1 year.

Effect of COVID-19-related lockdown on ophthalmic practice in Italy: A report from 39 institutional centers

BACKGROUND/OBJECTIVES

To compare the number of eye surgical procedures performed in Italy in the 2 months following the beginning of lockdown (study period) because of COVID-19 epidemic with those performed in the two earlier months of the same year (intra-year control) and in the period of 2019 corresponding to the lockdown (inter-year control).

METHODS

Retrospective analysis of surgical procedures carried out at 39 Academic hospitals. A distinction was made between elective and urgent procedures. Intravitreal injections were also considered. Percentages for all surgical procedures and incidence rate ratios (IRR) for rhegmatogenous retinal detachment (RRD) events were calculated. A p value <0.05 was considered significant.

RESULTS

A total of 20,886 versus 55,259 and 56,640 patients underwent surgery during the lockdown versus intra-and inter-year control periods, respectively. During the lockdown, only 70% of patients for whom an operation/intravitreal injection was recommended, finally underwent surgery; the remaining patients did not attend because afraid of getting infected at the hospital (23%), taking public transportation (6.5%), or unavailable swabs (0.5%). Elective surgeries were reduced by 96.2% and 96.4%, urgent surgeries by 49.7% and 50.2%, and intravitreal injections by 48.5% and 48.6% in the lockdown period in comparison to intra-year and inter-year control periods, respectively. IRRs for RRDs during lockdown dropped significantly in comparison with intra- and inter-year control periods (CI: 0.65-0.80 and 0.61-0.75, respectively, p < 0.001 for both).

CONCLUSION

This study provides a quantitative analysis of the reduction of eye surgical procedures performed in Italy because of the COVID-19 epidemic.

Risk factors for postoperative eye pain in patients with non-painful eye disease undergoing pars plana vitrectomy: the VItrectomy Pain (VIP) study

BACKGROUND

Pars plana vitrectomy (PPV), a surgical procedure used to treat different ophthalmic pathologies, could be associated with moderate to severe eye pain. The aim of the present study was to evaluate the incidence of postoperative eye pain and its risk factors following PPV in a selected population of patients with non-painful eye disease, receiving regional anesthesia and moderate sedation with benzodiazepines, without use of narcotics.

METHODS

Single-center, prospective observational cohort study. We recorded the presence of pain at operating room discharge, at 6 and 24 hours, using the numeric rating scale (NRS). We recorded also age, sex, ethnic origin, American Society of Anaesthesia physical status (ASA PS) classification, Charlson Comorbidity Index, the etiology of the vitreoretinal pathology, length of surgery, and type of surgical procedure performed.

RESULTS

Eye pain (NRS>3) was present in three patients (0.7%) at operating room discharge, 59 (13.2%) at six and 65 (14.6%) at 24 hours after surgery. LASSO logistic regression analysis identified age, ASA PS, race, along with tamponade as independent risk factors for eye pain at six hours. Scleral buckling was selected for eye pain at 24 hrs.

CONCLUSIONS

A protocol for pain control after PPV should be considered, especially in younger, non-Caucasian people, and patients with high ASA PS grade. Moreover, attention must be paid when additional surgical procedures are requested, restricting them to selected patients, and using the appropriate agent for intraocular tamponade.

Pneumatic retinopexy preceded by drainage of subretinal fluid for the treatment of severe bullous retinal detachment

PURPOSE

To compare the efficacy and safety outcomes of scleral buckling (SB) and drainage-injection-pneumoretinopexy (DIP), a modified pneumatic retinopexy technique, in which, before gas injection, subretinal fluid is drained with a simultaneous injection of balanced salt solution (BSS) in the vitreous chamber, for the treatment of severe superior bullous rhegmatogenous retinal detachment (SBRD).

METHODS

This prospective, randomized, comparative study included 58 eyes with severe SBRD that were randomized 1:1 to undergo SB or DIP. The main outcome measures included success rate, visual acuity, mean change in refractive error and surgery duration.

RESULTS

The primary anatomic success rate was 93% for both procedures. Both groups showed significantly improved visual acuity after surgery. The change in refractive error and surgery duration was significantly higher in the SB group. Drainage-injection-pneumoretinopexy (DIP) appeared to be less traumatic, but with a longer persistence of subretinal fluid in a greater number of patients.

CONCLUSION

Our findings suggested that both SB and DIP are safe and effective treatments yielding functional and anatomical recovery in patients with severe SBRD. However, the DIP technique may be easier and less costly, with a success rate similar to that of SB.

Changes in pupillometry associated with dissipated energy during phacoemulsification

PURPOSE

To investigate the effect of ultrasound level during phacoemulsification on pupil dynamics.

METHODS

Comparative retrospective study on patients who underwent routine cataract surgery at the Royal Liverpool University Hospital. Clinical parameters, anterior chamber measurements, axial length, surgeon grade, time of surgery, level of ultrasound used (cumulative dissipated energy, CDE), intra- and post-operative complications were collected. Pupil diameters were collected before and 4 ± 1 weeks after surgery in static scotopic, mesopic, photopic pupil conditions. Also, pupil dynamic measurements after luminous stimulus were recorded. Changes in static pupil diameters, relative dilation at 3.5 s after luminous stimulus, and time to reach 75% and 95% of maximum dilation were measured.

RESULTS

Forty-eight eyes of 24 patients (13 males) were included with a mean age of 73.1 ± 14.6 years. Mean CDE value was 18.11 ± 10.56. Mean scotopic pupil diameters decreased by 0.24 ± 0.48 mm (p = 0.021) in the operated eye. Significant correlation was found between reduction in scotopic pupil diameter and CDE (p = 0.05). A generalized linear model confirmed that the level of CDE was significantly associated with reduction in scotopic pupil diameter (p = 0.026). Patients who underwent surgeries with lower CDE (0 < CDE ⩽ 10 and 10 < CDE ⩽ 20) did not experience significant changes in scotopic pupil diameter after surgery (p = 0.28 and p = 0.79, respectively) as opposed to those with higher CDE (CDE > 20; p = 0.03).

CONCLUSION

Phacoemulsification cataract surgery and the cumulative dissipated energy may be associated with changes in pupil behaviour.

Clinical outcomes from out-of-hospital cardiac arrest in low-resource settings - A scoping review

AIM OF THE SCOPING REVIEW

Scientific recommendations on resuscitation are typically formulated from the perspective of an ideal resource environment, with little consideration of applicability in lower-income countries. We aimed to determine clinical outcomes from out-of-hospital cardiac arrest (OHCA) in low-resource countries, to identify shortcomings related to resuscitation in these areas and possible solutions, and to suggest future research priorities.

DATA SOURCES

This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We identified low-resource countries as countries with a low- or middle gross national income per capita (World Bank data). We performed a literature search on outcomes after OHCA in these countries, and we extracted data on the outcome. We applied descriptive statistics and conducted a post-hoc correlation analysis of cohort size and ROSC rates.

RESULTS

We defined 24 eligible studies originating from middle-income countries, but none from low-income regions, suggesting a reporting bias. The number of reported patients in these studies ranged from 54 to 3214. Utstein-style reporting was rarely used. Return of spontaneous circulation varied from 0% to 62%. Fifteen studies reported on survival to hospital discharge (between 1.0 and 16.7%) or favourable neurological outcome (between 1.0 and 9.3%). An inverse correlation was found for study cohort size and the rate of return of spontaneous circulation (ρ = -0.48, p = 0.034).

CONCLUSION

Studies of OHCA outcomes in low-resource countries are heterogeneous and may be compromised by reporting bias. Minimum cardiopulmonary resuscitation standards for low-resource settings should be developed collaboratively involving local experts, respecting culture and context while balancing competing health priorities.

Angiogenesis-Inflammation Cross Talk in Diabetic Retinopathy: Novel Insights From the Chick Embryo Chorioallantoic Membrane/Human Vitreous Platform

Pathological angiogenesis of the retina is a key component of irreversible causes of blindness, as observed in proliferative diabetic retinopathy (PDR). The pathogenesis of PDR is complex and involves vascular, inflammatory, and neuronal mechanisms. Several structural and molecular alterations associated to PDR are related to the presence of inflammation that appears to play a non-redundant role in the neovascular response that characterizes the retina of PDR patients. Vascular endothelial growth factor (VEGF) blockers have evolved over time for the treatment of retinal neovascularization. However, several limitations to anti-VEGF interventions exist. Indeed, the production of other angiogenic factors and pro-inflammatory mediators may nullify and/or cause resistance to anti-VEGF therapies. Thus, appropriate experimental models are crucial for dissecting the mechanisms leading to retinal neovascularization and for the discovery of more efficacious anti-angiogenic/anti-inflammatory therapies for PDR patients. This review focuses on the tight cross talk between angiogenesis and inflammation during PDR and describe how the chick embryo chorioallantoic membrane (CAM) assay may represent a cost-effective and rapid in vivo tool for the study of the relationship between neovascular and inflammatory responses elicited by the vitreous humor of PDR patients and for the screening of novel therapeutic agents.

Effects of the first month of lockdown for COVID-19 in Italy: A preliminary analysis on the eyecare system from six centers

Purpose:

To compare the number of eye surgical procedures performed in Italy during the first month of lockdown with those performed in the same period in 2019.

Methods:

Review of the surgical procedures performed from 10 March to 9 April 2019 and from 10 March to 9 April 2020 (the first month of lockdown because of the COVID-19 outbreak) at six academic institutional centers of Italy. A distinction was made between urgent procedures: any trauma repairment, trabeculectomy/drainage implant for glaucoma, any operation for rhegmatogenous retinal detachment (RRD) repair, pars plana vitrectomy (PPV) for vitreous hemorrhage (VH), macular hole, or retained lens fragments; elective procedures: corneal transplant, phacoemulsification for cataract extraction, silicone oil removal, and PPV for epiretinal membrane; and intravitreal injections (either anti-vascular endothelial growth factor [VEGF] or dexamethasone) to treat exudative maculopathies. The main outcome measure was the rate of reduction in urgent and elective surgeries performed.

Results:

Overall, 3624 and 844 surgical procedures were performed from 10 March to 9 April 2019 and from 10 March to 10 April 2020, respectively (−76.7% in 2020 compared to 2019, p < 0.0001). Urgent and elective surgical procedures and intravitreal injections of anti-VEGF drugs or dexamethasone reduced significantly in 2020 in comparison to 2019 (p < 0.0001 for urgent and elective surgeries and 0.01 for intravitreal injections).

Conclusion:

A significant reduction in the rate of urgent and elective surgeries and intravitreal injections was recorded during the first month of lockdown compared to the same period in 2019. With this analysis, the authors hope to provide some preliminary insights about the consequences of lockdown for the eyecare system in Italy.

Gene expression analysis identifies two distinct molecular clusters of idiopatic epiretinal membranes

Idiopathic epiretinal membranes (ERMs) are fibrocellular membranes containing extracellular matrix proteins and epiretinal cells of retinal and extraretinal origin. iERMs lead to decreased visual acuity and their pathogenesis has not been completely defined. Aim of this study was to provide a molecular characterization of iERMs by gene expression analysis. To this purpose, 56 iERMs obtained by pars plana vitrectomy were analyzed for the expression levels of genes encoding biomarkers of the cellular and molecular events occurring in iERMs. RT-qPCR analysis showed significant differences in the levels of cell population, extracellular matrix and cytokine/growth factor biomarkers among the iERMs investigated. Hierarchical clustering of RT-qPCR data identified two distinct iERM clusters, Cluster B samples representing transcriptionally "activated" iERMs when compared to transcriptionally "quiescent" Cluster A specimens. Further, Cluster B could be subdivided in two subgroups, Cluster B1 iERMs, characterized by a marked glial cell activation, and Cluster B2 samples characterized by a more pro-fibrotic phenotype. Preoperative decimal best-corrected visual acuity and post-surgery inner segment/outer grading values were higher in Cluster A patients, that showed a prevalence of fovea-attached type iERMs with near-normal inner retina, than in Cluster B patients, that presented more severe clinical and spectral domain optical coherence tomography (SD-OCT) features. In conclusion, this molecular characterization has identified two major clusters of iERM specimens with distinct transcriptional activities that reflect different clinical and SD-OCT features of iERM patients. This retrospective work paves the way to prospective whole-genome transcriptomic studies to allow a molecular classification of iERMs and for the identification of molecular signature(s) of prognostic and therapeutic significance.

European Resuscitation Council COVID-19 guidelines executive summary

Coronavirus disease 2019 (COVID-19) has had a substantial impact on the incidence of cardiac arrest and survival. The challenge is to find the correct balance between the risk to the rescuer when undertaking cardiopulmonary resuscitation (CPR) on a person with possible COVID-19 and the risk to that person if CPR is delayed. These guidelines focus specifically on patients with suspected or confirmed COVID-19. The guidelines include the delivery of basic and advanced life support in adults and children and recommendations for delivering training during the pandemic. Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the person’s presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice.

Central Serous Chorioretinopathy: Pathogenesis and Management

Central serous chorioretinopathy (CSC) is a common retina disease and has a relative high recurrence rate, etiology, and pathogenesis of which remains largely ambiguous. The effects on the retina are usually self-limited, although some people are left with permanent vision loss due to progressive and irreversible photoreceptor damage or retinal pigment epithelium atrophy. There have been a number of interventions used in CSC, including, but not limited to, laser treatment, photodynamic therapy (PDT), intravitreal injection of anti-vascular endothelial growth factor agents, and subthreshold lasers. It is not clear whether there is a clinically important benefit to treating acute CSC, which often resolves spontaneously as part of its natural history. Of the interventions studied to date, PDT and micropulse laser treatment appear the most promising.