Clinical ophthalmology最新文献

Purpose: To evaluate the outcomes of operating on "complex cataracts" by the glaucoma fellows.

Patients and methods: This was a retrospective study done at a tertiary referral eye care centre in eastern India. After obtaining IRB approval, a retrospective chart review of all patients who underwent "complex" cataract surgery by one of four long-term (2 years) glaucoma fellows between January 2016 and November 2020 was conducted. 'Complex' was defined as cataracts complicated with pseudoexfoliation syndrome, phacodonesis with or without blunt ocular trauma, posterior polar cataract, small pupil, co-existent corneal opacity or uveal coloboma, post-glaucoma filtering surgery, post-vitreoretinal surgery, co-existent glaucoma or post-laser iridotomy and monocular patients.

Results: Out of a total of 677 eyes done by the glaucoma fellows during the study period, 83 eyes had complex cataract surgery and completed the six-week post-operative follow-up. Intraoperative surgical complications like posterior capsular rent or vitreous loss were noted in 36 of the cases. Thirty of the eyes were left aphakic. Despite a high rate of complications, the LogMAR best-corrected visual acuity (mean ± standard deviation) improved from the preoperative level of 1.7 (±0.5) to 1.0 (± 0.8) at post-operative six weeks, significant at p < 0.001. As far as the surgeon's experience was concerned-less than or more than a year since joining the fellowship-there was statistically no difference in the final visual acuity. The group with greater experience had shorter surgical time and lesser complications though this difference was not statistically significant.

Conclusion: This is the first study in the literature reporting the outcomes of "complex" cataract surgery performed by glaucoma fellows. Though high rates of postoperative complications were noted in this study, the mean best-corrected visual acuity improved significantly in all eyes after the surgery.

Pythium insidiosum is an oomycete belonging to the phylum Straminipila and family Pythiaceae. It causes rapidly progressive vision-threatening keratitis. Clinically, microbiologically and morphologically, it closely resembles fungal keratitis; hence it is also labelled as a "parafungus". The clinical features mimicking fungus are subepithelial and stromal infiltrate, endo-exudates, corneal melt and hypopyon. The hallmark features of Pythium are tentacular projections, reticular dot-like infiltrate, peripheral furrowing and thinning, and rapid limbal spread. Microbiological corneal smearing on KOH and Gram stain reveal septate or aseptate, obtuse to perpendicular hyphae which mimic fungal hyphae. Culture on any nutritional agar reveals cream, cottonwool-like, fluffy colonies, and diagnosis is confirmed by zoospore formation by the leaf incarnation method. Medical management with antifungals and antibacterials still presents a dilemma. Early therapeutic keratoplasty has been the proposed treatment in most cases. We hypothesize that the prognosis of Pythium keratitis is governed by regional geographical variations, ulcer size and density on presentation, and initial treatment strategy. The available literature supporting the proposed hypothesis is also discussed, along with the hallmark features of Pythium and how it masquerades as other microorganisms causing keratitis. We also aim to propose a novel diagnostic and treatment algorithm for managing this vision-threatening keratitis.

Purpose: To evaluate the initial efficacy and safety of intravitreal faricimab in eyes previously treated for neovascular age-related macular degeneration (nARMD).

Patients and methods: A retrospective review of all patients with nARMD previously treated with anti-vascular endothelial growth factor (anti-VEGF) injections who received at least 3 intravitreal faricimab injections with at least 3 months of follow-up.

Results: A total of 190 eyes were included. Patients received a mean of 34.2±23 anti-VEGF injections over 182.41±128 weeks prior to switching to faricimab. Patients then received a mean of 6.99±2.3 faricimab injections with an average 34.88±8.2 weeks of follow-up. The mean best corrected visual acuities improved from 0.33±0.32 logMAR ≈20/43 to 0.27±0.32 logMAR ≈20/37 (P=0.0022). The central subfield thickness (CST) improved from 312±87μm to 287±71μm (P<0.0001). At the last clinical visit, 24% had no subretinal fluid or intraretinal fluid on optical coherence tomography. The mean dosing interval between the last two consecutive faricimab injections (7.64±6.2 weeks) was significantly longer than that for ranibizumab (5.16±2.0 weeks, P<0.001) or aflibercept (5.57±3.6 weeks, P<0.001). No patients developed idiopathic intraocular inflammation.

Conclusion: Intravitreal faricimab was associated with improved vision and CSTs, even in treatment-resistant nARMD eyes. The mean last dosing interval for faricimab was longer than for ranibizumab or aflibercept. No significant adverse events were directly attributed to faricimab during the study.

Purpose: To determine the effectiveness of subconjunctival application of a novel sirolimus liposomal formulation for the treatment of dry eye.

Methods: A randomized, triple-blind, Phase II clinical trial. Thirty-eight eyes of 19 patients were included. Nine patients (18 eyes) assigned to the sham group (Sham) and 10 patients (20 eyes) to sirolimus-loaded liposomes group (Sirolimus). The treatment group received three doses of subconjunctival liposome-encapsulated sirolimus and the sham group received three doses of liposomal suspension without sirolimus. Subjective (Ocular Surface Disease Index, OSDI) and measured (corrected distance visual acuity, conjunctival hyperemia, tear osmolarity, Schirmer's test, corneal/conjunctival staining and matrix metalloproteinase-9) variables were measured.

Results: Sirolimus-entrapped liposomes-treated group OSDI scores changed from 62.19 (± 6.07) to 37.8 (± 17.81) (p=0.0024), and conjunctival hyperemia from 2.0 (± 0.68) to 0.83 (± 0.61) (p<0.0001); Sham group with OSDI scores from 60.02 (± 14.2) to 36.02 (± 20.70) (p=0.01), and conjunctival hyperemia from 1.33 (± 0.68) to 0.94 (± 0.87) (p=0.048). All the other evaluated outcomes only showed significant differences in the sirolimus group: corneal/conjunctival staining score (p=0.0015), lipid layer interferometry (p=0.006), and inferior meibomian gland dropout (p=0.038). No local or systemic adverse effects regarding the medication itself were reported, and the administration route was well accepted.

Conclusion: Our findings suggest that sub-conjunctival sirolimus-loaded liposomes are effective in reducing both signs and symptoms of dry eye in patients with poorly controlled moderate-to-severe DED, while avoiding other topical administration adverse effects. Further investigation with a larger sample size is required to determine long-term effects.

Purpose: To assess the effectiveness of XEN45, either alone or in combination with phacoemulsification, in open-angle glaucoma (OAG) patients in clinical practice.

Methods: Retrospective and single-center study conducted on OAG patients who underwent XEN45 implant, either alone or in combination with cataract surgery. We compared the clinical outcomes of the eyes of thosewho underwent XEN-solo versus those who underwent XEN+Phacoemulsification. The primary endpoint was the mean change in intraocular pressure (IOP) from baseline to the last follow-up visit.

Results: A total of 154 eyes, 37 (24.0%) eyes that underwent XEN-solo and 117 (76.0%) eyes that underwent XEN+Phacoemulsification, were included. The mean preoperative IOP was significantly lowered from 19.1±5.0 mmHg to 14.9±3.8 mmHg at month-36, p<0.0001. Preoperative IOP was significantly lowered from 21.2±6.2 mmHg and 18.4±4.3 mmHg to 14.3±4.0 mm Hg and 15.2±3.7 mmHg at month-36 in the XEN-solo and XEN+Phacoemulsification groups, p<0.0004 and p=0.0009; with no significant differences between them. In the overall study population, the mean number of antiglaucoma medications was significantly reduced from 2.1±0.8 to 0.2±0.6, p<0.0001. There were no significant differences in the proportion of eyes with a final IOP ≤14 mmHg and ≤16 mmHg between XEN-solo and XEN+Phaco groups (p=0.8406 and 0.04970, respectively). Thirty-six (23.4%) eyes required a needling procedure.

Conclusion: XEN implant significantly lowered IOP and reduced the need of ocular hypotensive medication, while maintaining a good safety profile. Beyond week-1, there were no significant differences in IOP lowering between XEN-solo and XEN+Phacoemulsification groups.

Purpose: To determine the health economic opportunity cost or gain associated with performing pterygium excision surgery using the TissueTuck technique with cryopreserved amniotic membrane (AM) instead of conjunctival autograft (CAU).

Methods: We performed a literature review to determine the average surgical duration of pterygium surgery using CAU with fibrin glue or sutures to calculate the average time saved with the TissueTuck technique. Such time savings was then used to determine the opportunity revenue gain per national average Medicare reimbursement if adjusted to the average surgical duration of cataract surgery.

Results: The time savings achieved using the TissueTuck technique over CAU with fibrin glue is 8.9 min per procedure, which can be applied to additional MSICS or phacoemulsification procedures to generate an opportunity revenue gain of $1167 or $762 per 2022 National Average Medicare reimbursement, respectively. After subtracting the current list cost of AmnioGraft (ie, $645), the opportunity gain is $522 or $117 if the time saving is applied to the above procedures, respectively. Alternatively, the time savings achieved by using the TissueTuck technique over CAU with sutures is 23.4 min per procedure, which can be applied to additional MSICS or phacoemulsification procedures to generate an opportunity revenue gain of $3068 and $2004 per TissueTuck procedure or $2423 or $1359 when accounting for the list cost of AmnioGraft, respectively.

Conclusion: The TissueTuck surgical technique using cryopreserved AM for pterygium takes less time, has lower recurrence rates, and provides an opportunity gain compared to pterygium excision with CAU.

Bietti crystalline dystrophy (BCD) is a rare, genetically determined chorioretinal dystrophy presenting with intraretinal crystalline deposits and varying degrees of progressive chorioretinal atrophy commencing at the posterior pole. In some cases, there can be concomitant corneal crystals noted first in the superior or inferior limbus. CYP4V2 gene, a member of the cytochrome P450 family is responsible for the disease and more than 100 mutations have been defined thus far. However, a genotype-phenotype correlation has not been established yet. Visual impairment commonly occurs between the second and third decades of life. By the fifth or sixth decade of life, vision loss can become so severe that the patient may potentially become legally blind. Multitudes of multimodal imaging modalities can be utilized to demonstrate the clinical features, course, and complications of the disease. This present review aims to reiterate the clinical features of BCD, update the clinical perspectives with the help of multimodal imaging techniques, and overview its genetic background with future therapeutic approaches.

Purpose: To evaluate the prevalence of suicidal ideation and associated factors among older people with visual impairments attending an eye center during the COVID-19 pandemic.

Patients and methods: A total of 314 older people aged 60 and above with visual impairments who attended an eye center were included in this study. This was a hospital-based cross-sectional study conducted from February to July, 2022. Data were collected in person. Suicidal ideation was measured using the Columbia-Suicide Severity Rating Scale (C-SSRS). Multivariable logistic regression analysis was used to explore associations between related factors and suicidal ideation.

Results: Of 314 older people with visual impairments, the prevalence of suicidal ideation was 32.5%. Suicidal ideation was independently associated with diabetic retinopathy (adjusted odds ratio (AOR)=2.4, 95% confidence interval (CI): 1.0-5.8; p=0.038) and depression (AOR=6.3, 95% CI: 3.5-11.2; p<0.001).

Conclusion: This study found a relatively high prevalence of suicidal ideation among older people with visual impairments. There was also a significant association between depression and suicidal ideation among these individuals. Visual impairments can lead to negative émotions. This underscores the importance of addressing the mental health needs of older individuals with visual impairments, including suicide prevention efforts tailored to their needs. Ophthalmologists should be equipped with the skills necessary to identify the early signs of suicidal ideation and refer patients to mental healthcare specialists for appropriate treatment.

Purpose: To report the outcomes of medical and surgical management in patients diagnosed with aqueous misdirection syndrome (AMS).

Patients and methods: A retrospective chart review of all cases diagnosed with AMS at a single tertiary care eye center during the period from 2014 to 2021. Outcome measures were anatomical success (deepening of the anterior chamber (AC)), functional success (improvement in visual acuity), and treatment success (control of intraocular pressure (IOP)).

Results: A total of 26 eyes with AMS from 24 patients were included. The patients were followed for a mean duration of 24 ± 18 months. Although some patients initially responded to medical and laser therapy, all but one (3.8%) eventually required surgery during the first 3 months after presentation. The mean duration from presentation until surgery was 45.9 ± 45.8 days (range: 2-119 days). The majority of cases (69.2%) were managed by pars plana vitrectomy. At the last follow-up visit, anatomical success was achieved in 20 (76%) eyes, 15 (57%) eyes had a final visual acuity that was either similar to or better than baseline, and successful control of IOP was achieved in 17 (65%) eyes. Univariate analysis revealed that a history of trabeculectomy as a cause of AMS was a risk factor for treatment failure (OR, 7.8; 95% CI, 1.16-52.35; P, 0.02).

Conclusion: Our findings indicate that medical and laser management of AMS provide temporary control, and almost all patients eventually require surgery within the first 3 months. A history of trabeculectomy was found to be a risk factor for treatment failure.