Current Opinion in Ophthalmology最新文献

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.

Purpose of review: This review examines the emerging role of artificial intelligence (AI) in the detection and management of pediatric retinal diseases, with a focus on systems that achieve expert-level performance in classifying fundus abnormalities. We highlight models developed for clinical application as assistive or autonomous tools with the potential to enhance early identification and referral, streamline care delivery, and improve access to care.

Recent findings: AI systems, have shown high diagnostic accuracy in identifying retinal pathology associated with retinopathy of prematurity, pediatric myopia, diabetic retinopathy, and retinoblastoma. Many of these systems have potential utility in real-world screening, supplementing clinical decision-making, and guiding early intervention. In addition, autonomous AI systems can increase access in low-resource, remote settings and areas where access to pediatric ophthalmologists is limited. Ongoing advances include integration with nonmydriatic fundus photography, smartphone-based imaging, and image-free diagnostic modalities, further expanding reach and applicability.

Summary: AI holds transformative promise for pediatric retina care by providing scalable, accurate, and accessible screening solutions. These systems have demonstrated to enhance clinical expertise, minimize interobserver variability, facilitate timely referrals and support decision-making. As integration of algorithms into clinical and community settings is established, AI is poised to become an essential component of pediatric ophthalmology, improving early detection and reducing the global burden of preventable childhood blindness.

Purpose of review: With the rise of 'oculomics' and the application of advanced artificial intelligence techniques in healthy ageing, retinal imaging, the only way we can directly visualize the microvascular circulation, is expanding beyond ophthalmology into broader systemic health monitoring. The purpose of this review is to summarize recent advances in this rapidly evolving field and assess the opportunities, challenges, and future directions of the use of oculomics in translating into real-world clinical use.

Recent findings: Retinal imaging modalities, such as color fundus photography, optical coherence tomography (OCT), OCT angiography (OCTA), and wide-field imaging, are increasingly integrated with deep learning algorithms to detect, predict, and manage a broad spectrum of systemic diseases, including cardiovascular, cerebrovascular, renal, metabolic, and neurodegenerative disorders, as well as less commonly studied conditions. While research in more established areas is beginning to address clinical translation and implementation, significant challenges remain before these technologies can be reliably adopted in long-term, real-world healthcare settings.

Summary: Artificial intelligence applied to retinal imaging has matured from proof-of-concept classifiers to externally validated, occasionally regulated tools that noninvasively profile systemic conditions. Multiplexed foundation models and multimodal transformers herald a shift toward holistic 'oculomics' platforms, yet prospective multicenter trials, equitable performance auditing, and health-economic evaluations are essential before widescale clinical adoption.

Purpose of review: The current article provides an overview of the utility of artificial intelligence approaches to aid in the design, recruitment, execution, and dissemination of ophthalmic clinical trials.

Recent findings: Within the last decade, artificial intelligence has heralded a new age for ophthalmology, with novel applications habitually appearing within the literature. Though clinical trials are considered the gold standard for driving evidence-based practice, remarkably few studies have examined the potential for machine learning to augment the clinical trial pipeline. Clinical trials within ophthalmology often do not reach planned endpoints due to insufficient enrolment, cost overruns, and can lack reliability from unblinded outcome assessors. Ones that do, frequently take longer to enroll patients than intended. Artificial intelligence-based approaches have recently been shown to be effective in identifying eligible clinical trial participants using both imaging and text data.

Summary: Given the key role of clinical trials in the advancement of ophthalmic clinical practice, trialists should consider the potential for artificial intelligence-powered tools to enhance the design, recruitment, and delivery of future studies.

Purpose of review: To highlight the ocular manifestations associated with COVID-19 and review the evidence surrounding proposed associations with corneal transplant rejection and uveitis reactivation.

Recent findings: SARS-CoV-2 has been associated with various ocular manifestations, most commonly conjunctivitis. Less frequently, more severe complications such as uveitis, retinal vascular occlusions, and neuro-ophthalmic syndromes have been reported. These manifestations are theorized to occur secondary to both direct viral invasion as well as secondary systemic inflammation and immune dysregulation. While case reports suggest a possible link between COVID-19 infection and vaccination and corneal graft rejection, large cohort studies and meta-analyses have not confirmed an association. In contrast, retrospective data suggest a slight increase in uveitis recurrence following COVID-19 infection and vaccination in patients with prior uveitis.

Summary: Ocular involvement in COVID-19 ranges from mild conjunctivitis to rare, vision-threatening inflammatory and vascular complications. While case reports have suggested temporal links between COVID-19 infection or vaccination and corneal transplant rejection or uveitis reactivation, current evidence does not support an association with graft rejection, and only a slight increase in uveitis recurrence has been observed in certain high-risk populations. With longer follow-up and prospective analyses, a clearer understanding of underlying mechanisms and risk factors may emerge to better guide ophthalmic management during and beyond the pandemic.