Pub Date : 2023-06-18DOI: 10.1080/17469899.2023.2224565
I. Mirzayev, A. Gündüz, Ö. Gündüz
{"title":"Anterior segment optical coherence tomography in iris and ciliary body tumors: a systematic review","authors":"I. Mirzayev, A. Gündüz, Ö. Gündüz","doi":"10.1080/17469899.2023.2224565","DOIUrl":"https://doi.org/10.1080/17469899.2023.2224565","url":null,"abstract":"","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41816819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-04DOI: 10.1080/17469899.2023.2245143
B. Darlow
ABSTRACT Introduction Primary prevention of retinopathy of prematurity (ROP) is sparingly covered in recent literature but is both possible and highly cost-effective Areas covered The variation in incidence of ROP between neonatal units (NICUs) in large neonatal networks provides clues as to primary prevention of ROP. Differences in beneficial evidence-based care practices include use of antenatal corticosteroids, labor ward care, use of caffeine, facilitating human milk feeding, improved nutrition, and prevention of sepsis. Recent large trials show oxygen saturation targets should be higher than 85–89% to improve survival of very preterm infants, whilst avoiding fluctuations in oxygenation. Multifaceted quality improvement programs in neonatal networks that focus on using known evidence-based practices and addressing attitudes, knowledge, and clinical biases have resulted in steady improvement in ROP rates over several years. Consistently, better performing NICUs have a positive ‘culture’ that fosters team work, camaraderie, and learning opportunities. In poorly resourced low and middle-income countries (LMICs), increasing awareness of ROP and undertaking data collection are important first steps, and there are several low-cost measures that can be taken to reduce ROP rates. Literature searches were undertaken through PubMed. Expert opinion ROP has a multifactorial etiology, and a multifaceted approach is required for prevention.
{"title":"Primary prevention of ROP: more can be done in all settings","authors":"B. Darlow","doi":"10.1080/17469899.2023.2245143","DOIUrl":"https://doi.org/10.1080/17469899.2023.2245143","url":null,"abstract":"ABSTRACT Introduction Primary prevention of retinopathy of prematurity (ROP) is sparingly covered in recent literature but is both possible and highly cost-effective Areas covered The variation in incidence of ROP between neonatal units (NICUs) in large neonatal networks provides clues as to primary prevention of ROP. Differences in beneficial evidence-based care practices include use of antenatal corticosteroids, labor ward care, use of caffeine, facilitating human milk feeding, improved nutrition, and prevention of sepsis. Recent large trials show oxygen saturation targets should be higher than 85–89% to improve survival of very preterm infants, whilst avoiding fluctuations in oxygenation. Multifaceted quality improvement programs in neonatal networks that focus on using known evidence-based practices and addressing attitudes, knowledge, and clinical biases have resulted in steady improvement in ROP rates over several years. Consistently, better performing NICUs have a positive ‘culture’ that fosters team work, camaraderie, and learning opportunities. In poorly resourced low and middle-income countries (LMICs), increasing awareness of ROP and undertaking data collection are important first steps, and there are several low-cost measures that can be taken to reduce ROP rates. Literature searches were undertaken through PubMed. Expert opinion ROP has a multifactorial etiology, and a multifaceted approach is required for prevention.","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44521048","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-04DOI: 10.1080/17469899.2023.2245147
I. Halkiadakis, Dimitrios S. Ladas, K. Chatzistefanou, N. Markomichelakis
Anterior uveitis (AU) is the commonest type of uveitis [1,2]. Most cases (48–70%) are considered idiopathic. HLA-B27-associated spondyloarthritis is the most common systemic disease associated with adult AU. It was reported in 18–32% of patients with AU in Western countries and in 6–13% of patients with AU in Asia [3]. AU in children is also frequently associated with juvenile idiopathic arthritis. Several other causes of AU have been described in the literature including herpes family virus, syphilis, tuberculosis, sarcoidosis, tubulointerstitial nephritis and uveitis syndrome, and Adamantiades–Bechet’s disease (ABD) [4]. In terms of disease duration, AU has been divided into acute, recurrent, and chronic. A chronic course is defined as episode duration over 3 months or relapses within less than 3 months of treatment cessation [5]. Chronic AU has been linked to an increased risk for loss of vision from serious complications such as glaucoma, cataract, band keratopathy, cystoid macular edema, and phthisis bulbi [4]. Prompt identification of possible infectious causes or systemic associations may prevent complications and loss of vision and can positively affect the overall visual prognosis and the patient’s quality of life [6]. For example, in patients with juvenile idiopathic arthritis (JIA)-associated chronic AU, the use of immunosuppression reduces the risk of vision loss by ~ 40% [7] and an early identification of herpetic AU may significantly reduce the risk of glaucoma and cataract formation [8].
{"title":"Cytomegalovirus anterior uveitis: how does it compare to the characteristics of other anterior uveitides to provide unique management opportunities","authors":"I. Halkiadakis, Dimitrios S. Ladas, K. Chatzistefanou, N. Markomichelakis","doi":"10.1080/17469899.2023.2245147","DOIUrl":"https://doi.org/10.1080/17469899.2023.2245147","url":null,"abstract":"Anterior uveitis (AU) is the commonest type of uveitis [1,2]. Most cases (48–70%) are considered idiopathic. HLA-B27-associated spondyloarthritis is the most common systemic disease associated with adult AU. It was reported in 18–32% of patients with AU in Western countries and in 6–13% of patients with AU in Asia [3]. AU in children is also frequently associated with juvenile idiopathic arthritis. Several other causes of AU have been described in the literature including herpes family virus, syphilis, tuberculosis, sarcoidosis, tubulointerstitial nephritis and uveitis syndrome, and Adamantiades–Bechet’s disease (ABD) [4]. In terms of disease duration, AU has been divided into acute, recurrent, and chronic. A chronic course is defined as episode duration over 3 months or relapses within less than 3 months of treatment cessation [5]. Chronic AU has been linked to an increased risk for loss of vision from serious complications such as glaucoma, cataract, band keratopathy, cystoid macular edema, and phthisis bulbi [4]. Prompt identification of possible infectious causes or systemic associations may prevent complications and loss of vision and can positively affect the overall visual prognosis and the patient’s quality of life [6]. For example, in patients with juvenile idiopathic arthritis (JIA)-associated chronic AU, the use of immunosuppression reduces the risk of vision loss by ~ 40% [7] and an early identification of herpetic AU may significantly reduce the risk of glaucoma and cataract formation [8].","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44476930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-04DOI: 10.1080/17469899.2023.2245145
J. Pearce, B. Rai
ABSTRACT Introduction The day-1 topical antibiotic treatment for bacterial keratitis (BK) can have a significant impact on treatment outcomes. Symptoms associated with this condition (pain, photophobia, blepharospasm and increased lacrimation) may compromise the effectiveness of topical antibiotic treatment by reducing the antibiotic contact time with the cornea. Topical ocular local anaesthetics (TOLAs) have the potential to alleviate these symptoms and thus potentiate the effect of the antibiotic drops instilled. Areas covered The literature on possible ocular side-effects of TOLAs was searched using Google and PubMed databases (Filters: Humans, English, abstract available), with no filters applied for date of publication. Relevant papers were reviewed, and possible barriers to their use on day-1 in the treatment of BK were identified, examined, and either found to be not applicable to short term use or strategies were identified to resolve any barriers. Published evidence to support the possible potentiation of antibiotic effect via the use of TOLAs was also reviewed. Expert opinion Perceived barriers to the short-term use of TOLAs in BK are not supported by the literature, and there is evidence to suggest that higher corneal antibiotic concentrations may be achieved by using TOLAs in conjunction with topical antibiotic drops in BK on day-1.
{"title":"Topical ocular local anaesthetics as an adjunctive measure in the day-1 treatment of bacterial keratitis","authors":"J. Pearce, B. Rai","doi":"10.1080/17469899.2023.2245145","DOIUrl":"https://doi.org/10.1080/17469899.2023.2245145","url":null,"abstract":"ABSTRACT Introduction The day-1 topical antibiotic treatment for bacterial keratitis (BK) can have a significant impact on treatment outcomes. Symptoms associated with this condition (pain, photophobia, blepharospasm and increased lacrimation) may compromise the effectiveness of topical antibiotic treatment by reducing the antibiotic contact time with the cornea. Topical ocular local anaesthetics (TOLAs) have the potential to alleviate these symptoms and thus potentiate the effect of the antibiotic drops instilled. Areas covered The literature on possible ocular side-effects of TOLAs was searched using Google and PubMed databases (Filters: Humans, English, abstract available), with no filters applied for date of publication. Relevant papers were reviewed, and possible barriers to their use on day-1 in the treatment of BK were identified, examined, and either found to be not applicable to short term use or strategies were identified to resolve any barriers. Published evidence to support the possible potentiation of antibiotic effect via the use of TOLAs was also reviewed. Expert opinion Perceived barriers to the short-term use of TOLAs in BK are not supported by the literature, and there is evidence to suggest that higher corneal antibiotic concentrations may be achieved by using TOLAs in conjunction with topical antibiotic drops in BK on day-1.","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41349439","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-04DOI: 10.1080/17469899.2023.2237193
N. Miller, A. Arnold
ABSTRACT Introduction Ischemic optic neuropathies (IONs) are the leading cause of sudden, permanent optic nerve-related visual loss. Areas covered There are three types of anterior and posterior (retrobulbar) IONs: nonarteritic, perioperative, and arteritic. In this review, we discuss the clinical manifestations, management, and prognoses – visual and systemic – of each type. A literature search was conducted via MEDLINE (PubMed) 1 January 1973 to 1 April 2023. Expert opinion There is no consistently beneficial treatment for the nonarteritic IONs. Patients who have experienced either spontaneous nonarteritic anterior ION (NAION) or an acute optic neuropathy following uncomplicated cataract surgery should be warned that they may have an increased risk of a similar event in their fellow eye if they undergo cataract surgery in that eye. Early recognition of perioperative ION after non-ocular surgery is crucial so that anemia and hypotension can be corrected as soon as possible, hopefully resulting in visual improvement. Finally, arteritic ION requires early recognition and timely treatment with systemic corticosteroids to prevent subsequent visual loss in the fellow eye as well as the many other complications of giant cell arteritis. The interleukin-6 inhibitor tocilizumab can be used to reduce both the dose of steroids and the duration steroids are needed.
{"title":"Clinical presentation of ischemic optic neuropathies","authors":"N. Miller, A. Arnold","doi":"10.1080/17469899.2023.2237193","DOIUrl":"https://doi.org/10.1080/17469899.2023.2237193","url":null,"abstract":"ABSTRACT Introduction Ischemic optic neuropathies (IONs) are the leading cause of sudden, permanent optic nerve-related visual loss. Areas covered There are three types of anterior and posterior (retrobulbar) IONs: nonarteritic, perioperative, and arteritic. In this review, we discuss the clinical manifestations, management, and prognoses – visual and systemic – of each type. A literature search was conducted via MEDLINE (PubMed) 1 January 1973 to 1 April 2023. Expert opinion There is no consistently beneficial treatment for the nonarteritic IONs. Patients who have experienced either spontaneous nonarteritic anterior ION (NAION) or an acute optic neuropathy following uncomplicated cataract surgery should be warned that they may have an increased risk of a similar event in their fellow eye if they undergo cataract surgery in that eye. Early recognition of perioperative ION after non-ocular surgery is crucial so that anemia and hypotension can be corrected as soon as possible, hopefully resulting in visual improvement. Finally, arteritic ION requires early recognition and timely treatment with systemic corticosteroids to prevent subsequent visual loss in the fellow eye as well as the many other complications of giant cell arteritis. The interleukin-6 inhibitor tocilizumab can be used to reduce both the dose of steroids and the duration steroids are needed.","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42992168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-04DOI: 10.1080/17469899.2023.2233697
M. Bagheri, Nader Salari, Naser Aghaei, M. Yarmohammadi
ABSTRACT Background Many studies introduced intravitreal injections of anti-vascular endothelial growth factors (VEGFs) as a new strategy for safer and more convenient vitrectomy in patients with severe proliferative diabetic retinopathy (PDR). While possible side effects such as progression of vitreoretinal fibrosis should be kept in mind, these may be prevented by proper preoperative timing of injection. Research design and methods This study was conducted based on the systematic review guidelines in four steps: definition of search strategy, selecting and evaluating studies, checking inclusion and exclusion criteria, and statistical analysis. Eighteen clinical trials with a total sample size of 1165 patients were included. According to the timing of injection, patients were divided into three groups: injection 72 hours, injection 3–7 days, and injection 7–21 days before surgery. Results The lowest risk of intraoperative hemorrhage, the minimum duration of surgery and the lowest need for silicone oil (SO) tamponade was in the injection group 7–21 days before surgery. The rate of iatrogenic retinal break during surgery and the necessity for relaxing retinotomy in the injection group 72 hours before surgery was lower than the other two groups. However, there were limited data regarding the requirement of relaxing retinotomy, the need to inject SO, and the occurrence of iatrogenic retinal break. Conclusions This meta-analysis showed, to prevent tractional complications, it is recommended to inject within 3 days before surgery.
{"title":"Appropriate timing schedule for intravitreal anti-VEGF injection as adjuvant therapy before pars-plana vitrectomy in proliferative diabetic retinopathy, a meta analysis","authors":"M. Bagheri, Nader Salari, Naser Aghaei, M. Yarmohammadi","doi":"10.1080/17469899.2023.2233697","DOIUrl":"https://doi.org/10.1080/17469899.2023.2233697","url":null,"abstract":"ABSTRACT Background Many studies introduced intravitreal injections of anti-vascular endothelial growth factors (VEGFs) as a new strategy for safer and more convenient vitrectomy in patients with severe proliferative diabetic retinopathy (PDR). While possible side effects such as progression of vitreoretinal fibrosis should be kept in mind, these may be prevented by proper preoperative timing of injection. Research design and methods This study was conducted based on the systematic review guidelines in four steps: definition of search strategy, selecting and evaluating studies, checking inclusion and exclusion criteria, and statistical analysis. Eighteen clinical trials with a total sample size of 1165 patients were included. According to the timing of injection, patients were divided into three groups: injection 72 hours, injection 3–7 days, and injection 7–21 days before surgery. Results The lowest risk of intraoperative hemorrhage, the minimum duration of surgery and the lowest need for silicone oil (SO) tamponade was in the injection group 7–21 days before surgery. The rate of iatrogenic retinal break during surgery and the necessity for relaxing retinotomy in the injection group 72 hours before surgery was lower than the other two groups. However, there were limited data regarding the requirement of relaxing retinotomy, the need to inject SO, and the occurrence of iatrogenic retinal break. Conclusions This meta-analysis showed, to prevent tractional complications, it is recommended to inject within 3 days before surgery.","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48855654","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-04DOI: 10.1080/17469899.2023.2216931
Otavio Azevedo Magalhaes
I read with great interest the review article recently published by McMonnies [1] regarding eye rubbing-related intra-ocular pressure (IOP) elevation in the development and progression of keratoconus (KC). Although we congratulate the author for highlighting the importance of eye rubbing and KC pathogenesis, some important points that support the primary role of IOP elevation in the context of eye rubbing still need to be considered. First, the relationship between KC and the onset and progression of primary open angle glaucoma (POAG) cannot be observed in a clinical setting [2]. If elevated IOP during rubbing is so relevant in terms of corneal bulging, rubbing would also be expected to damage the optic nerve and retinal fiber layer. In addition, in very asymmetric cases, an eye with severe KC would present an increased cup-to-disc ratio compared to mild or form frustre contralateral eye. Again, this finding has not been observed [3]. The concept of corneal bulging/distention due to IOP forces needs to be investigated. The concept invokes the notion of an increase in surface area occurs via a stretching process [4]. However, this idea is not exactly an accurate description of the morphology of the keratoconic cornea. A true bulge would necessarily dictate an increase in surface area of the cornea, such as in keratoglobus in which the surface expands [5]. In contrast, surface area tends to be conserved to the same degree as in corneas with KC, promoting an isometric type of distortion or warping in the majority of cases. Hence, the flattening seen in the periphery of keratoconic corneas (increased prolateness) corresponds to a coupling effect that compensates for the increase in curvature in the cone region [6]. What happens to a young patient’s cornea when he is subject to constantly elevated IOP? It has been reported that cases of childhood glaucoma corneas have flatter keratometry, greater diameter, and relatively thicker corneas than normal corneas [7,8]. Only a statistically significant increase in posterior corneal elevation in eyes with childhood glaucoma, both unoperated and operated, was found, although no significant difference in anterior corneal elevation and pachymetry was observed [9]. Finally, I agree with the author that eye rubbing is the most important risk factor for KC development and progression (perhaps sine qua non) and causes substantial transient IOP elevation. However, the lack of relationship between KC, POAG, and childhood glaucoma in addition to the morphology of corneal deformation questions the importance of IOP elevation in KC pathogenesis. Funding
{"title":"Under pressure: keratoconus and intraocular pressure elevation evidence","authors":"Otavio Azevedo Magalhaes","doi":"10.1080/17469899.2023.2216931","DOIUrl":"https://doi.org/10.1080/17469899.2023.2216931","url":null,"abstract":"I read with great interest the review article recently published by McMonnies [1] regarding eye rubbing-related intra-ocular pressure (IOP) elevation in the development and progression of keratoconus (KC). Although we congratulate the author for highlighting the importance of eye rubbing and KC pathogenesis, some important points that support the primary role of IOP elevation in the context of eye rubbing still need to be considered. First, the relationship between KC and the onset and progression of primary open angle glaucoma (POAG) cannot be observed in a clinical setting [2]. If elevated IOP during rubbing is so relevant in terms of corneal bulging, rubbing would also be expected to damage the optic nerve and retinal fiber layer. In addition, in very asymmetric cases, an eye with severe KC would present an increased cup-to-disc ratio compared to mild or form frustre contralateral eye. Again, this finding has not been observed [3]. The concept of corneal bulging/distention due to IOP forces needs to be investigated. The concept invokes the notion of an increase in surface area occurs via a stretching process [4]. However, this idea is not exactly an accurate description of the morphology of the keratoconic cornea. A true bulge would necessarily dictate an increase in surface area of the cornea, such as in keratoglobus in which the surface expands [5]. In contrast, surface area tends to be conserved to the same degree as in corneas with KC, promoting an isometric type of distortion or warping in the majority of cases. Hence, the flattening seen in the periphery of keratoconic corneas (increased prolateness) corresponds to a coupling effect that compensates for the increase in curvature in the cone region [6]. What happens to a young patient’s cornea when he is subject to constantly elevated IOP? It has been reported that cases of childhood glaucoma corneas have flatter keratometry, greater diameter, and relatively thicker corneas than normal corneas [7,8]. Only a statistically significant increase in posterior corneal elevation in eyes with childhood glaucoma, both unoperated and operated, was found, although no significant difference in anterior corneal elevation and pachymetry was observed [9]. Finally, I agree with the author that eye rubbing is the most important risk factor for KC development and progression (perhaps sine qua non) and causes substantial transient IOP elevation. However, the lack of relationship between KC, POAG, and childhood glaucoma in addition to the morphology of corneal deformation questions the importance of IOP elevation in KC pathogenesis. Funding","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43186222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-04DOI: 10.1080/17469899.2023.2216932
C. McMonnies
The editor, I appreciate the opportunity to respond to Dr Gatinel’s comments as they address some key issues in relation to the pathogenesis of keratoconus (KC). In regard to links between KC and primary open angle glaucoma, Hashemi and coauthors reviewed the associations between KC and posterior segment structures and reported extensive evidence of morphological and functional changes in the retina, optic nerve head and choroid being found in KC patients [1]. These changes included significantly larger disc and cup areas and deeper cup depth in KC patients than in non-KC individuals [1]. It is possible that exposure to rubbing-related or other mechanisms for episodes of elevated intraocular pressure (IOP) might be involved in the development of posterior segment changes observed in KC patients [2]. For instance, increased tissue hydrostatic pressure and ubiquitination processes that could occur during episodes of IOP elevation may help explain both retinal and corneal cellular changes seen in KC patients [2]. Accordingly, increased hydrostatic pressure in corneal stroma may damage keratocytes and reduce their collagen maintenance functions. Poorly maintained collagen may increase the possibility of thinning and reduced resistance to IOP distending forces with associated increased susceptibility for bulging responses during episodes of IOP elevation [2]. In regard to the notion of bulging corneal responses due to IOP forces and an expected increase in corneal surface area: in the earlier stages of KC development, it appears that stromal fibrils/lamellae may not significantly stretch in response to IOP distending forces. That the corneal surface area is conserved can be explained by the concepts of biomechanical coupling [3] or curvature transfer [4]. These explanations involve steepening/bulging/protrusion of a central/para-central/pre-cone corneal area that is less resistant to IOP, which is compensated for by a flattening of curvature in a diametrically opposed area. The lamellae length required to form the bulge is provided by reduced curvature in the flattened zone. Thus, at least in the earlier stages of KC development, corneal surface area is not significantly changed despite a localized steepened area of bulge response. Colour topographical maps of early KC will sometimes very clearly show the compensating flatter peripheral area diametrically opposed to a steeper/bulging/pre-cone central or para-central area. Correction with rigid contact lenses appears to alter corneal topography such that this observation is not often apparent subsequently. KC corneas assume a conical shape in the most advanced cases [5]. and stretching/elongation of stromal fibrils and lamellae may be part of cone formation as well as an increase in corneal surface area. As far as rubbing being the sine qua non mechanism for KC pathogenesis, there is the need to consider patients who don’t have abnormal rubbing habits. For these patients KC development/progression may
{"title":"The pathogenesis of KERATOCONUS","authors":"C. McMonnies","doi":"10.1080/17469899.2023.2216932","DOIUrl":"https://doi.org/10.1080/17469899.2023.2216932","url":null,"abstract":"The editor, I appreciate the opportunity to respond to Dr Gatinel’s comments as they address some key issues in relation to the pathogenesis of keratoconus (KC). In regard to links between KC and primary open angle glaucoma, Hashemi and coauthors reviewed the associations between KC and posterior segment structures and reported extensive evidence of morphological and functional changes in the retina, optic nerve head and choroid being found in KC patients [1]. These changes included significantly larger disc and cup areas and deeper cup depth in KC patients than in non-KC individuals [1]. It is possible that exposure to rubbing-related or other mechanisms for episodes of elevated intraocular pressure (IOP) might be involved in the development of posterior segment changes observed in KC patients [2]. For instance, increased tissue hydrostatic pressure and ubiquitination processes that could occur during episodes of IOP elevation may help explain both retinal and corneal cellular changes seen in KC patients [2]. Accordingly, increased hydrostatic pressure in corneal stroma may damage keratocytes and reduce their collagen maintenance functions. Poorly maintained collagen may increase the possibility of thinning and reduced resistance to IOP distending forces with associated increased susceptibility for bulging responses during episodes of IOP elevation [2]. In regard to the notion of bulging corneal responses due to IOP forces and an expected increase in corneal surface area: in the earlier stages of KC development, it appears that stromal fibrils/lamellae may not significantly stretch in response to IOP distending forces. That the corneal surface area is conserved can be explained by the concepts of biomechanical coupling [3] or curvature transfer [4]. These explanations involve steepening/bulging/protrusion of a central/para-central/pre-cone corneal area that is less resistant to IOP, which is compensated for by a flattening of curvature in a diametrically opposed area. The lamellae length required to form the bulge is provided by reduced curvature in the flattened zone. Thus, at least in the earlier stages of KC development, corneal surface area is not significantly changed despite a localized steepened area of bulge response. Colour topographical maps of early KC will sometimes very clearly show the compensating flatter peripheral area diametrically opposed to a steeper/bulging/pre-cone central or para-central area. Correction with rigid contact lenses appears to alter corneal topography such that this observation is not often apparent subsequently. KC corneas assume a conical shape in the most advanced cases [5]. and stretching/elongation of stromal fibrils and lamellae may be part of cone formation as well as an increase in corneal surface area. As far as rubbing being the sine qua non mechanism for KC pathogenesis, there is the need to consider patients who don’t have abnormal rubbing habits. For these patients KC development/progression may ","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43156077","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-04DOI: 10.1080/17469899.2023.2207010
C. Mazzotta, Manuela Pulvirenti, Marco Zagari, S. Jihad, Ashraf Armia Balamoun
ABSTRACT Introduction the review reports the results of photodynamic accelerated crosslinking (ACXL) protocols focusing on the novelties of high fluence pulsed light transepithelial (Epi-On) ACXL treatments. Areas covered Review covers the outcomes of accelerated crosslinking (ACXL) for all thickness ectatic corneas, including the new epithelium-on (Epi-On) strategies with progressively enhanced fluence, higher riboflavin concentrations and pulsed light irradiation that are considered a promising way forward of photodynamic CXL therapy of Keratoconus (KC), addressing the role of CXL in combination with excimer laser corneal remodeling and lamellar keratoplasty. Literature research is focused on advancements in transepithelial procedures and high fluence accelerated crosslinking treatments looking at CXL plus combined procedures. Expert opinion Today CXL can be considered to all intents a customized corneal photodynamic therapy (CPDT) of ectasia with different application modalities. ACXL protocols optimized the clinical workflow and patient compliance reducing the time of treatment to 20–25 minutes, adapting fluence, improving oxygen kinetic and riboflavin loading. Standardized protocols for thin corneas improved the issue of thin corneas. High irradiance pulsed light Epi-ON ACXL performed with and without iontophoresis, at air-room oxygenation or adding intraoperative supplemental oxygen, reduced the gap of efficacy with Epi-Off techniques, creating the conditions for transition to the Epi-On.
摘要引言综述报道了光动力加速交联（ACXL）方案的结果，重点是高通量脉冲光跨上皮（Epi-on）ACXL治疗的新颖性。综述涵盖的领域涵盖了加速交联（ACXL）治疗所有厚度扩张性角膜的结果，包括具有逐渐增强的注量、更高的核黄素浓度和脉冲光照射的新上皮开启（Epi-on）策略，这些策略被认为是光动力学CXL治疗角角膜（KC）的一种有前途的方法，探讨CXL在准分子激光角膜重塑和板层角膜移植术中的作用。文献研究的重点是跨上皮手术和高通量加速交联治疗的进展，着眼于CXL加联合手术。今天的专家意见CXL可以被认为是一种定制的角膜光动力疗法（CPDT），具有不同的应用模式。ACXL方案优化了临床工作流程和患者依从性，将治疗时间缩短至20-25 分钟，适应通量，改善氧动力学和核黄素负荷。薄角膜的标准化方案改善了薄角膜的问题。在空气室充氧或添加术中补充氧气的情况下，使用和不使用离子电渗法进行的高辐照度脉冲光Epi ON ACXL，减少了Epi-Off技术的疗效差距，为过渡到Epi-ON创造了条件。
{"title":"Crosslinking for progressive keratoconus: is there room for improvement?","authors":"C. Mazzotta, Manuela Pulvirenti, Marco Zagari, S. Jihad, Ashraf Armia Balamoun","doi":"10.1080/17469899.2023.2207010","DOIUrl":"https://doi.org/10.1080/17469899.2023.2207010","url":null,"abstract":"ABSTRACT Introduction the review reports the results of photodynamic accelerated crosslinking (ACXL) protocols focusing on the novelties of high fluence pulsed light transepithelial (Epi-On) ACXL treatments. Areas covered Review covers the outcomes of accelerated crosslinking (ACXL) for all thickness ectatic corneas, including the new epithelium-on (Epi-On) strategies with progressively enhanced fluence, higher riboflavin concentrations and pulsed light irradiation that are considered a promising way forward of photodynamic CXL therapy of Keratoconus (KC), addressing the role of CXL in combination with excimer laser corneal remodeling and lamellar keratoplasty. Literature research is focused on advancements in transepithelial procedures and high fluence accelerated crosslinking treatments looking at CXL plus combined procedures. Expert opinion Today CXL can be considered to all intents a customized corneal photodynamic therapy (CPDT) of ectasia with different application modalities. ACXL protocols optimized the clinical workflow and patient compliance reducing the time of treatment to 20–25 minutes, adapting fluence, improving oxygen kinetic and riboflavin loading. Standardized protocols for thin corneas improved the issue of thin corneas. High irradiance pulsed light Epi-ON ACXL performed with and without iontophoresis, at air-room oxygenation or adding intraoperative supplemental oxygen, reduced the gap of efficacy with Epi-Off techniques, creating the conditions for transition to the Epi-On.","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42445786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-04DOI: 10.1080/17469899.2023.2205124
A. Nguyen, Maria Cabrera-Aguas, S. Watson
ABSTRACT Background The aim of this paper is to report the adherence of clinician prescription to the evidence-based herpes simplex keratitis (HSK) guideline at the Sydney Eye Hospital, Australia, in order to assess the sustainability of guideline implementation. Methods A retrospective review was conducted of patients, aged 18 years and above, receiving anti-viral treatment for HSK at the Sydney Eye Hospital from 1 January 2018 to 31 December 2019. Patients were identified from pharmacy records, viral swab results, and hospital coding data. Results Three hundred and thirty-six eyes of 335 patients, median age 58 years (range 18–103); 61% males were included. Anti-viral therapy was given for therapeutic and prophylactic indications at presentation in 287 (86%) and 48 (14%) patients, respectively. The dose of prescribed antivirals was in alignment with the guidelines in 69% (231/335) of eyes compared to 75% (64/85) in 2017 (P = 0.254) in our prior study. For the type of HSK, alignment with the guidelines was found in 80/112 eyes (71%) with epithelial, 43/68 (63%) with stromal, 13/17 (76%) with endothelial, 52/90 (58%) with keratouveitis, and 43/48 (90%) on prophylaxis. Conclusions Clinicians were similarly adherent to a HSK treatment guideline 2 years after its implementation. Regular activities are needed to sustain knowledge.
{"title":"Herpes simplex keratitis (HSK) local treatment guideline audit 2018–2019","authors":"A. Nguyen, Maria Cabrera-Aguas, S. Watson","doi":"10.1080/17469899.2023.2205124","DOIUrl":"https://doi.org/10.1080/17469899.2023.2205124","url":null,"abstract":"ABSTRACT Background The aim of this paper is to report the adherence of clinician prescription to the evidence-based herpes simplex keratitis (HSK) guideline at the Sydney Eye Hospital, Australia, in order to assess the sustainability of guideline implementation. Methods A retrospective review was conducted of patients, aged 18 years and above, receiving anti-viral treatment for HSK at the Sydney Eye Hospital from 1 January 2018 to 31 December 2019. Patients were identified from pharmacy records, viral swab results, and hospital coding data. Results Three hundred and thirty-six eyes of 335 patients, median age 58 years (range 18–103); 61% males were included. Anti-viral therapy was given for therapeutic and prophylactic indications at presentation in 287 (86%) and 48 (14%) patients, respectively. The dose of prescribed antivirals was in alignment with the guidelines in 69% (231/335) of eyes compared to 75% (64/85) in 2017 (P = 0.254) in our prior study. For the type of HSK, alignment with the guidelines was found in 80/112 eyes (71%) with epithelial, 43/68 (63%) with stromal, 13/17 (76%) with endothelial, 52/90 (58%) with keratouveitis, and 43/48 (90%) on prophylaxis. Conclusions Clinicians were similarly adherent to a HSK treatment guideline 2 years after its implementation. Regular activities are needed to sustain knowledge.","PeriodicalId":39989,"journal":{"name":"Expert Review of Ophthalmology","volume":null,"pages":null},"PeriodicalIF":0.7,"publicationDate":"2023-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44941872","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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