Current Opinion in Ophthalmology最新文献

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.

Purpose of review: Middle segment surgery (MSS) refers to ophthalmic surgical intervention through the pars plana to prevent or manage anterior segment abnormality and surgical challenges/complications. It has gained interest in recent years due to its expanding indications and utility across ophthalmic subspecialties. Although MSS has been employed for decades, its integration into contemporary ophthalmic surgery requires a multidisciplinary understanding of both anterior and posterior segment diagnostics, treatment options and surgical techniques.

Recent findings: Although the nomenclature MSS may be relatively new, there is significant evidence in the literature that the intervention of choice to resolve anterior segment, especially lens-related, abnormality and postoperative surgical complications may be best offered not only through the limbus but also through the pars plana. The surgeon may have training in anterior or posterior segment techniques. Cross training may be ideal in this setting.

Summary: This article reviews foundational skills necessary for MSS, outlines current clinical indications, and proposes pathways for training, credentialing, and future innovation.

Purpose of review: The growing threat of antibiotic-resistant pathogens, particularly in ocular infections like bacterial keratitis, necessitates alternative therapeutic strategies. This review evaluates the potential therapeutic role of predatory bacteria as novel live antimicrobials, offering a timely exploration of their potential in overcoming resistance mechanisms such as biofilm formation and persister cell development.

Recent findings: Predatory bacteria, including Bdellovibrio bacterovorus and Micavibrio aerguinosavorus selectively target Gram-negative bacteria, including Pseudomonas aeruginosa, while sparing Gram-positive ocular surface. They exhibit rapid bactericidal activity and efficacy against biofilms, persister cells, and antibiotic-resistant pathogens, but induce little inflammation. Advances in storage and delivery methods, such as lyophilization, cryomicroneedles, and thermoresponsive hydrogels, have potential to increase their therapeutic feasibility. However, in-vivo efficacy remains variable and their narrow spectrum limits effectiveness against Gram-positive pathogens.

Summary: Predatory bacteria present a promising alternative to traditional antibiotics in ocular therapeutics, particularly for drug-resistant infections. Integration of predatory bacteria with bacteriophages or conventional antibiotics may further optimize their potential. Continued translational research is essential to address current limitation and to validate their safety and efficacy for human or veterinary applications.

Purpose of review: To summarize emerging therapeutic strategies for neovascular (wet) age-related macular degeneration (nAMD), with emphasis on recent translational and clinical developments.

Recent findings: The nAMD treatment landscape is rapidly evolving. Gene therapies (e.g. ABBV-RGX-314, ADVM-022, and 4D-150) have demonstrated sustained intraocular anti-VEGF expression with reduced injection burden in phase 2 and 3 programs, validating the 'biofactory' concept. Tyrosine kinase inhibitors delivered via intravitreal or suprachoroidal implants (e.g. EYP-1901, OTX-TKI, and CLS-AX) show potential for twice-yearly or less frequent dosing. Moreover, emerging therapeutic approaches increasingly target non-VEGF pathogenic pathways, reflecting a shift toward mechanistically diverse vascular stabilization and neuroprotection strategies. These include multitargeted biologics that couple anti-angiogenic and anti-inflammatory effects (e.g. KSI-501, IBI-302, and AG-73305), as well as agents modulating FGF2 signaling, Wnt activation, complement regulation, and cellular metabolism.

Summary: Therapeutic innovation in nAMD is transitioning from incremental refinements in intravitreal anti-VEGF delivery to strategies aimed at extending durability or targeting alternative contributory pathways. Long-term safety, efficacy, and durability will determine which of these candidates redefine standard care.

Purpose of review: This review examines commonly prescribed systemic medications and their possible associations with age-related macular degeneration (AMD) development and progression. With the limitations and risks of current intravitreal therapies, there is growing interest in oral pharmacotherapy for AMD management. The following review synthesizes observational studies, meta-analyses, and ongoing clinical trials to evaluate the potential effects of commonly used systemic medications on AMD.

Recent findings: Metformin demonstrates conflicting evidence, with several meta-analyses and large cohort study showing reduced AMD odds, while a recent randomized phase II trial found no effect on geographic atrophy progression. For statins, emerging evidence suggests that treatment duration exceeding 2 years and medium-intensity to high-intensity dosing may confer protection against AMD development. Aspirin demonstrates discordant results between different study designs: two large randomized controlled trials showed no benefit for AMD, while a 10-year observational study suggested protective effects.Fenofibrates show promise in preclinical models but require additional clinical investigation. Danicopan also shows modest effects in complement-related disorders and is currently undergoing a phase 2 trial to evaluate efficacy in patients with geographic atrophy. Finally, dopamine agonists appear to improve visual acuity and reduce subretinal fluid and central retinal thickness in newly diagnosed exudative AMD, as shown in an open-label pilot study, but require further investigation.

Summary: Multiple systemic medications have highlighted mixed or stage-dependent benefits on AMD development and progression. Some agents such as metformin and aspirin have shown conflicting findings, having been evaluated in randomized trials and large observational studies. Other medications including GLP-1 agonists, dopamine agonists, statins, fenofibrates, and danicopan show early promise in more limited studies, but require further clinical validation.