Current Opinion in Ophthalmology最新文献

Purpose of review: To provide an update on new glaucoma drainage devices and implants.

Recent findings: Glaucoma drainage implant devices are currently indicated for medically or surgically uncontrolled glaucoma, especially in eyes at high risk for trabeculectomy failure. The devices used can differ, but many offer similar long-term outcomes. Due to the differences in devices, some of the side effect profiles may differ.

Summary: Long-term outcomes show that nonvalved devices (Ahmed ClearPath, Baerveldt, Molteno, Paul Glaucoma Implant) achieve greater intraocular pressure reduction and lower medication burden than valved devices (Ahmed valved implant) but come with a higher risk of hypotony-related complications; all devices have similar overall complication rates and comparable surgical failure rates at 2-5  years. The most recent updates as of 2025 highlight that Ahmed ClearPath ST and Paul Glaucoma Implant (only available internationally) offer streamlined implantation and favorable safety profiles, and Molteno and Baerveldt continue to provide durable IOP control in refractory cases. Two more devices, Calibreye (Myra Vision) and VisiPlate (Avisi), are undergoing trials with promising initial outcomes. The Calibreye implant is showing promising short-term data, with less patients experiencing unwanted side effect of bleb needling and while offering the ability to titrate to maximize patient benefit. An upcoming device, GORE glaucoma drainage device implant is showing promises preclinical results and offer unique device material composition.

Purpose of review: To summarize the recent literature on the clinical and surgical management of retinoschisis.

Recent findings: Novel analyses of the existing imaging modalities, including ultra wide-field imaging, near-infrared imaging, blue light reflectance, and color Doppler ultrasound, can be adjuncts to existing diagnostic tools such as ocular coherence tomography (OCT) and clinical examination to differentiate between rhegmatogenous retinal detachment (RRD) and retinoschisis.

Summary: Degenerative retinoschisis can be challenging to differentiate from a RRD through clinical examination. Although ocular coherence tomography (OCT) is the typical approach to diagnosing retinoschisis, there have been many promising diagnostic developments to better prognosticate and differentiate between similar entities. Given the difficulty in managing these cases, medical and surgical management are typically at the discretion of the treating physician.

Purpose of review: PED are corneal epithelial defects that fail to heal after 2 weeks and pose a significant therapeutic challenge. In recent years, insulin has emerged as a promising and effective therapy for promoting reepithelialization of the ocular surface, playing a role in the management of PED. The purpose of this article is to provide a summary of the role of topical insulin for persistent corneal epithelial defects (PED) management.

Recent findings: Based on current evidence, topical insulin merits an early placement within the therapeutic pathway and may be considered after conventional therapy, before the use of autologous serum. Several studies suggest that insulin eye drops can facilitate faster and more consistent epithelial healing, potentially offering greater efficacy than autologous serum in some cases. Moreover, patients who do not respond to insulin often require escalation to surgical interventions such as amniotic membrane transplantation. Overall, topical insulin appears to represent a well tolerated, cost-effective, and promising option that could serve as an intermediate step between standard medical treatments and surgical management in PED.

Summary: The evidence summarized in this review demonstrates that insulin shows considerable promise in managing PED, reinforcing the importance of further investigations to clarify its place in clinical practice. Ongoing clinical trials aim to validate the effectiveness of topical insulin for a range of ocular diseases and to benchmark its performance against other established treatment options.

Purpose of review: To summarize trends in supply and demand for vitreoretinal fellowship positions in the United States, describe applicant characteristics and match outcomes, and discuss future workforce needs and diversity in the field.

Recent findings: Fellowship applications and positions have increased, with medical and surgical retina programs accounting for the largest share of positions. Despite this growth, match rates have declined, and a persistent portion of positions remain unfilled, likely concentrated among less established or non Association of University Professors of Ophthalmology (AUPO) programs. Predictors of matching include completing more interviews and ranking more programs as well as completing residency training in the United States. Women and individuals underrepresented in medicine remain markedly underrepresented in the vitreoretinal pipeline relative to need. Interest in vitreoretinal fellowship is driven by advanced surgical exposure, perceived prestige, financial considerations, and mentorship during residency.

Summary: Aligning supply with demand will require expanding high-quality, AUPO-compliant training; improving transparency about medical versus surgical positions; and targeted mentorship/sponsorship to diversify the pipeline. Given projected growth in retinal disease, strategic recruitment and training are essential to ensure equitable access to imaging, injections, laser, and surgery.

Purpose of review: Investigations over the past 2 years involving novel genomics pathways, imaging techniques, risk factors, and therapeutic interventions have sought to better understand and manage central serous retinopathy (CSR). While most cases of acute CSR are self-resolving, chronic CSR remains a challenging condition to manage given response to therapy may be limited and the risk of permanent, severe vision loss. In this work, we present the latest insights on disease pathophysiology and management for acute and chronic cases of CSR, highlighting data from randomized control trials and meta-analyses to compare efficacy of treatment options.

Recent findings: There is no difference in best corrected visual acuity (BCVA) or resolution of subretinal fluid (SRF) in cases of chronic CSR that are treated with half-dose/half-fluence photodynamic therapy (PDT) versus full-strength/full-fluence therapy, making half-dose/half-fluence a reasonable option to avoid the atrophic retinal changes that may be more likely with full-strength treatment. Laser therapy could be considered as an alternative to PDT for treating chronic CSR in cases of verteporfin shortage; however, the statistically significant reduction in subretinal fluid seen on optical coherence tomography (OCT) does not translate to a significant improvement in BCVA after intervention. While there may be an early improvement in BCVA and SRF in cases of chronic CSR for which treatment with mineralocorticoid receptor antagonist is initiated, this effect does not appear to persist with extended follow up.

Summary: With ongoing extensive research on the disease process of CSR and a more nuanced understanding of the factors that increase risk of disease, observation remains the mainstay of management for acute CSR. For chronic CSR, PDT, laser, or anti-VEGF may be considered, with advances in imaging allowing OCTA to be a less invasive alternative method to dye angiography for detecting neovascularization.

Purpose of review: Marfan syndrome is a connective tissue disorder with several vision-threatening ocular manifestations. This study synthesizes recent advances in the surgical approach to ocular complication of Marfan syndrome including ectopia lentis, early cataract, glaucoma, and retinal detachment.

Recent findings: Recent literature highlights advances in capsular support devices and alternative fixation methods for ectopia lentis, including long-term outcomes with modified capsular tension rings, suture-less scleral fixation, and iris-claw intraocular lenses. Pediatric cohorts underscore elevated risks of retinal detachment following lens removal, particularly when capsular remnants persist, emphasizing the importance of complete removal and vigilant follow-up. In highly myopic Marfan eyes, modern intraocular lens power calculation formulas demonstrate improved refractive predictability, though pediatric patients remain prone to progressive myopic shift. For glaucoma, tailored modifications to trabeculectomy and tube shunt techniques address the challenges of thin sclera and ocular surface fragility. Contemporary retinal detachment series reveal high lifetime risk, with surgical success often requiring multiple procedures, and outcomes closely tied to macular status and presence of proliferative vitreoretinopathy.

Summary: Advances across anterior and posterior segment surgery have improved visual outcomes for Marfan patients, but long-term risks remain substantial. Individualized surgical planning, early detection of complications, and long-term surveillance are essential to optimize outcomes in this high-risk population.

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.