Current Opinion in Ophthalmology最新文献

Purpose of review: Rapid advances in large language models (LLMs) have led to the emergence of agentic artificial intelligence (AI) systems capable of autonomously performing complex scientific tasks. This review examines recent developments in agentic AI, highlighting their transformative potential for ophthalmology research and clinical practice, and discusses associated ethical considerations.

Recent findings: Recent studies demonstrate that agentic AI systems can autonomously execute tasks traditionally performed by human researchers, including peer review, hypothesis generation, systematic reviews, and experimental design. Notable examples include AI-generated manuscripts accepted through peer review, automated systematic reviews outperforming human accuracy and efficiency, and performing complex biomedical analyses across diverse domains. Although direct ophthalmology-specific applications remain nascent, the field's data-rich nature positions it ideally for adopting agentic AI in several areas such as automated chart review, health economics modeling, and enhanced image analysis.

Summary: Agentic AI represents a paradigm shift in scientific research, offering significant opportunities to enhance productivity, rigor, and innovation in ophthalmology. However, integration into clinical and research workflows necessitates careful consideration of ethical issues, including authorship attribution, data privacy, bias mitigation, and accountability. Clear governance frameworks, rigorous validation standards, and interdisciplinary training will be essential to responsibly harness agentic AI in ophthalmology.

Purpose of review: Modern presbyopia-correcting intraocular lenses (IOLs) offer a potential solution to address the rising postoperative demand and expectations for spectacle independence following cataract surgery. However, IOL calculation and selection becomes more complex when presented with previous corneal refractive surgery (CRS) or co-existing corneal conditions. This review explores the use of presbyopia-correcting IOLs in eyes with co-existing corneal conditions or surgically altered corneas.

Recent findings: Careful consideration and selection is required in patients with co-existing corneal conditions who desire spectacle independence. Presbyopia-correcting IOLs have been shown to be safe and provide good uncorrected vision in eyes with previous CRS. Modern biometry formulas have improved predictability in eyes with previous CRS, though evidence related to presbyopia-correcting IOLs is limited. Pinhole IOLs may be suitable for eyes with irregular/aberrated corneas. Further evidence regarding presbyopia-correcting IOLs is required in eyes with dry eye disease, keratoconus, and corneal graft. Knowledge of the range of available IOLs are key to optimizing visual quality and achieving spectacle independence.

Summary: Patients with prior CRS or co-existing corneal disease(s) present unique challenges when considering presbyopia-correcting IOLs. While promising options are available, successful outcomes depend on careful patient selection, thorough corneal assessment, and realistic management of patient expectations.

Purpose of review: To review recent advances in the surgical management of dense white cataracts, focusing on preoperative assessment, biometry, capsulotomy techniques, phacoemulsification systems, and surgical outcomes.

Recent findings: Swept-source optical coherence tomography (SS-OCT) biometers now achieve nearly universal axial length measurements even in dense lenses, improving refractive predictability. Anterior segment OCT and Scheimpflug imaging facilitate detection of intralenticular fluid pockets and capsular thinning, guiding decompression strategies to prevent anterior capsule tears. Innovations in manual capsulorhexis, preoperative Nd:YAG (neodymium-doped yttrium aluminum garnet) decompression, and device-based techniques (precision pulse capsulotomy and selective laser capsulotomy) have improved reproducibility and reduced Argentinian flag sign incidence. Low-energy femtosecond laser-assisted cataract surgery further enhances endothelial safety in selected cases. In phacoemulsification, newer platforms with advanced fluidics and tips have decreased cumulative energy use, turbulence, and endothelial cell loss. For very dense nuclei, manual small-incision cataract surgery remains a practical alternative with lower endothelial trauma in specific settings.

Summary: Advances in ocular imaging, biometry, capsulotomy, and phacoemulsification technology have significantly improved the safety and predictability of dense white cataract surgery. Incorporating these innovations into surgical practice has reduced the incidence of intraoperative complications, including anterior capsular tears, posterior capsule ruptures, and endothelial cell loss, while enhancing refractive outcomes.

Purpose of review: Diabetes mellitus may influence different stages of cataract surgery, from preoperative evaluation to postoperative recovery. With the rapid increase in the global prevalence of diabetes, understanding evidence-based strategies for optimizing surgical outcomes is critical.

Recent findings: Studies have found that fixed glycated hemoglobin (HbA1c) thresholds alone should not be used to determine the timing of surgery. Instead, a macula-first approach, integrating retinal co-management and optical coherence tomography (OCT) for diabetic patients, allows for tailored decision-making. Key advancements include ocular surface optimization to enhance biometry accuracy, proactive perioperative anti-inflammatory regimens combining NSAIDs and corticosteroids, and selective use of intravitreal anti-VEGF or corticosteroid therapy for diabetic macular edema (DME). Lens choice should refrain from multifocal optics in eyes with diabetic macular diseases. Emerging equity frameworks underscore the need to replace systemic cut-offs with risk-based protocols to enhance access and outcomes.

Summary: Modern cataract surgery in patients with diabetes requires an individualized retina-integrated approach that emphasizes inflammation control and macular preservation. Embedding equity-driven, OCT-based pathways ensures that surgical excellence extends to populations most affected by diabetes-related vision loss.

Purpose of review: To provide an updated review of manual small incision cataract surgery (MSICS), including training innovations, advancements in surgical techniques, system-level performance, and equity implications in global cataract care.

Recent findings: As global cataract burden continues to rise, MSICS has gained traction as a cost-effective and scalable solution, particularly in low and middle-income countries (LMICs). Simulator-based training and new surgical tools have enhanced early proficiency among trainees. Recent data highlight MSICS as a procedure with comparable complication rates and patient-reported satisfaction to phacoemulsification, assuming proficiency of the surgeon. Key research gaps persist in skill transferability, long-term outcomes, and sex disparities in access.

Summary: MSICS remains a pivotal surgical technique in the fight against global cataract blindness. Its affordability and adaptability to resource-limited settings make it a critical part of international efforts to expand cataract surgical coverage and promote equitable eye care delivery.

Purpose of review: Cataract surgery in keratoconus remains one of the most challenging settings in anterior segment surgery. This review summarizes recent evidence (2020-2025) on intraocular lens (IOL) power calculation, surgical strategies, and adjunctive treatments, highlighting current limitations and future perspectives.

Recent findings: Advances in keratoconus-specific formulas such as Barrett True-K and Kane-KC, particularly when posterior corneal curvature is measured, have improved refractive accuracy compared with conventional formulas, though prediction errors remain higher than in normal eyes. Toric IOLs are effective in carefully selected mild-to-moderate cases, with multimeasurement calculators improving astigmatic prediction and a 2025 systematic review confirming safety and stability. Small-aperture optics (IC-8) may increase depth of focus, but keratoconus-specific evidence is limited. Staged approaches, including intracorneal ring segments, cross-linking, and DALK in advanced disease, improve safety and predictability. Emerging technologies such as artificial intelligence-based calculators and premium IOLs show promise but require further validation.

Summary: Despite significant progress, outcomes in keratoconus remain less predictable than in normal eyes. Careful patient selection, keratoconus-adjusted formulas, and staged surgical strategies are essential. Future priorities include prospective validation of formulas, integration of artificial intelligence tools, and evaluation of adjustable optics.

Purpose of review: Toric intraocular lenses (IOL) predictably correct corneal astigmatism and are an important part of the cataract and refractive surgeon's toolbox.

Recent findings: Advances in toric IOL technology, preoperative biometry, IOL power calculations, and IOL alignment have resulted in excellent visual outcomes and achievement of spectacle independence. Despite these advancements, the primary challenges faced in toric IOL use remain choosing the optimal IOL toricity and properly aligning the IOL.

Summary: Toric IOL are an effective way to correct corneal astigmatism, and advancements in lens selection and design have improved their functionality for patients. This review summarizes these advances and reports on upcoming technologies.

Purpose: Cataract surgery, the most commonly performed ophthalmic procedure, can result in corneal endothelial cell loss (ECL), which can have a lasting impact due to the endothelium's limited regenerative capacity. This review highlights surgical technologies and considerations that can provide protection of the corneal endothelium.

Recent findings: Endothelial cell density (ECD) at birth is about 3,000-5,000 cells/mm 2 and decreases 0.3-0.6% per year, with the adult eye endothelial cell density being approximately 2000-3000 cells/mm 2 . Most ECL occurs within the first three months after surgery, with attributing factors including shallow anterior chamber depth (ACD), low baseline ECD, and high cumulative dissipated energy (CDE), as well as patient-specific comorbidities. Diabetes has been shown to play a role in corneal endothelium recovery, as central corneal thickness (CCT) was found to be significantly higher in diabetic patients after cataract surgery at one month compared to nondiabetic patients, although not at six months in a meta-analysis. Modern fluidics platforms enhance chamber stability and minimize turbulence, and low-perfusion phacoemulsification has decreased ECL rates in high-risk eyes. Corneal tunnel length has been identified as an intraoperative factor; in eyes with short anterior chamber depth, longer tunnel lengths are associated with greater ECL. Microincision surgery, ultrasound energy modulation, and femtosecond laser use provide additional benefits. Hydrogen-enriched irrigating solutions were found to potentially significantly reduce early ECL, and chondroitin sulfate-hyaluronic acid ophthalmic viscosurgical devices (OVDs) further lowered both cell loss and corneal edema.

Summary: Advances in surgical technology, combined with individualized planning based on risk factors and anterior segment anatomy, enable minimization of ECL and optimize visual outcomes.

Purpose of review: To evaluate the association between insurance status and the selection of toric premium intraocular lenses (IOLs) among patients undergoing cataract surgery with astigmatism.

Recent findings: In this retrospective study of 4525 patients (7299 eyes), 71.3% of eyes received conventional IOLs, and 28.7% received premium IOLs, of which 34.8% were toric lenses. Logistic regression with adjustment for age, sex, and surgeon was used to assess associations between insurance status and IOL selection. Patients with commercial insurance were significantly more likely to select toric IOLs (14%) than those with Medicare (9.2%, P  < 0.001) and Medicare Advantage (7.6%, P  < 0.001). Among eyes with moderate-to-severe astigmatism (≥1.5 D), 40.7% were estimated to be eligible for toric correction, yet only 24.5% received a toric IOL.

Summary: Insurance status significantly influences toric IOL selection, with lower utilization observed among patients with Medicare and Medicare Advantage. Many patients deemed eligible for toric correction did not receive a toric IOL, suggesting underutilization likely driven by cost and insurance coverage limitations. With astigmatic correction becoming more common in cataract surgery, policy discussions should balance clinical efficacy and affordability of toric IOLs to improve access and visual outcomes.