Current Opinion in Ophthalmology最新文献

Purpose of review: Alongside the development of large language models (LLMs) and generative artificial intelligence (AI) applications across a diverse range of clinical applications in Ophthalmology, this review highlights the importance of evaluation of LLM applications by discussing evaluation metrics commonly adopted.

Recent findings: Generative AI applications have demonstrated encouraging performance in clinical applications of Ophthalmology. Beyond accuracy, evaluation in the form of quantitative and qualitative metrics facilitate a more nuanced assessment of LLM output responses. Several challenges limit evaluation including the lack of consensus on standardized benchmarks, and limited availability of robust and curated clinical datasets.

Summary: This review outlines the spectrum of quantitative and qualitative evaluation metrics adopted in existing studies, highlights key challenges in LLM evaluation, to catalyze further work towards standardized and domain-specific evaluation. Robust evaluation to effectively validate clinical LLM applications is crucial in closing the gap towards clinical integration.

Purpose of review: Photobiomodulation (PBM) is a noninvasive therapy utilising low-level light energy to stimulate cellular processes, modulate inflammatory pathways, enhance mitochondrial activity, promote tissue regeneration. With growing interest in PBM as a potential treatment modality, this review synthesises current evidence and highlights challenges of implementing PBM across various ophthalmic conditions.

Recent findings: Current ophthalmic applications of PBM can be categorised into established and exploratory therapies, differentiated primarily by the attainment of regulatory approval. Established applications of PBM include the treatment of dry eye disease and nonexudative age-related macular degeneration, while the use of PBM is still largely exploratory in conditions such as diabetic macular oedema and retinopathy of prematurity. Regardless of the level of regulatory authorisation, the application of PBM in each ophthalmic condition presents with distinct challenges requiring further research for comprehensive validation.

Summary: While PBM holds promise as a novel therapeutic option, its long-term efficacy and safety remains to be fully established. Standardised treatment guidelines and larger randomised controlled trials are essential to optimise its use in future clinical practice.

Purpose of review: Neovascular glaucoma (NVG) is a severe secondary glaucoma precipitated by ocular ischemia and abnormal neovascularization, resulting in elevated intraocular pressure (IOP) and vision loss if not promptly addressed. This study evaluates recent advances in both medical and surgical management of NVG, focusing on strategies that integrate anti-vascular endothelial growth factor (VEGF) therapy, retinal ablation, and evolving surgical techniques.

Recent findings: Anti-VEGF agents remain central to NVG treatment, with newer agents and combination regimens showing sustained neovascular suppression, alongside panretinal photocoagulation as an additional cornerstone in reducing neovascular drive. Glaucoma drainage devices continue to have prominence for their ability to bypass fibrotic outflow pathways, while trabeculectomy augmented with mitomycin C continues to offer a viable option in select cases. Cyclodestructive procedures, including micropulse transscleral cyclophotocoagulation and endoscopic cyclophotocoagulation, provide alternative surgical avenues for refractory cases. Novel studies including lipidomic analyses present novel metabolic pathways that are potentially implicated in NVG pathogenesis, suggesting future targets beyond VEGF.

Summary: Timely recognition and comprehensive treatment - encompassing IOP control, ischemic drive reduction, and inflammation management - remain critical in the management of NVG. As research illuminates additional molecular targets and refines surgical interventions, the promise of a more personalized, biomarker-driven approach to NVG management continues to grow.

Purpose of review: Many ocular neovascular diseases, including diabetic retinopathy (DR) and diabetic macular edema (DME), are significant complications that can worsen during pregnancy, posing risks to vision. Antivascular endothelial growth factor (anti-VEGF) agents represent the mainstay of DR and DME treatment in nonpregnant populations. However, their use in pregnant populations remain controversial due to concerns over fetal safety. This review explores the available literature on anti-VEGF use during pregnancy, evaluating maternal and fetal outcomes, and incorporating lessons learned from their recent use in treating retinopathy of prematurity (ROP).

Recent findings: Although human data on the safety of anti-VEGF agents during pregnancy remain limited, available studies suggest that systemic absorption is minimal, and concerns regarding potential effects on fetal angiogenesis largely theoretical. Case reports and retrospective studies have not consistently demonstrated harm. Furthermore, several studies examining long-term systemic effects of anti-VEGF use in treating premature infants with ROP reveal no association with adverse neurodevelopmental outcomes when compared to untreated ROP or ROP treated with laser photocoagulation alone.

Summary: While the use of anti-VEGF agents in pregnancy remains controversial, recent evidence suggests they should not be categorically excluded as a treatment option. Until more causal studies emerge, treatment decisions should be individualized, balancing disease severity, maternal visual function, and fetal safety.

Purpose of review: To review the role of microbial cultures in managing endophthalmitis following cataract surgery and intravitreal injections.

Recent findings: The endophthalmitis vitrectomy study (EVS) continues to guide the management of endophthalmitis including its recommendation for intraocular vitreous sampling. Vitreous cultures have better diagnostic yield than aqueous cultures. Advances in culture techniques have improved the efficiency and sensitivity of pathogen identification. While culture results are useful for prognostication, microbiology data rarely changes management in endophthalmitis following cataract surgery or intravitreal injections. Endophthalmitis managed without microbial cultures had similar outcomes to eyes managed with microbial cultures.

Summary: Despite advances in culture techniques, most institutions still rely on gram stain and microbial cultures, often requiring several days for results. Initial administration of empiric antibiotics occurs before microbiology data becomes available, limiting the utility of cultures in clinical management. Despite concerns for antibiotic resistance, the large majority of postcataract surgery and postintravitreal injection endophthalmitis pathogens are susceptible to vancomycin and ceftazidime. Given this, obtaining intraocular specimens can be deferred if it poses a delay to prompt treatment with intravitreal antibiotics. Emerging culture techniques hold promise for more rapid and sensitive pathogen identification, which could change the landscape of culture guidelines and improve clinical usefulness.

Purpose of review: Retinal displacement is an occasional yet underrecognized sequela of rhegmatogenous retinal detachment (RRD) repair that can cause postoperative visual distortions and anisekonia. While retinal surgeons strive to achieve single-surgery success, more emphasis and understanding should also be placed on optimizing visual outcomes following RRD repair, including minimizing retinal distortions. This review explores the pathophysiology, clinical manifestations, imaging modalities, risk factors, and preventive strategies associated with retinal displacement.

Recent findings: Retinal displacement is associated with significant visual disturbances - most notably metamorphopsia, aniseikonia, and spatial mislocalization - despite preserved visual acuity. Imaging advances, particularly optical coherence tomography (OCT) overlays and OCT homography, have improved detection over traditional fundus autofluorescence. Risk factors for displacement include macula-off detachments, extensive detachment area, use of a complete intraocular gas fill, and surgical modality, with pneumatic retinopexy and scleral buckling associated with lower displacement rates. Computer modeling has suggested biomechanical forces contributing to displacement.

Summary: Retinal displacement significantly affects postoperative visual quality following RRD repair. Although often missed on standard examination, improved imaging and surgical refinement offer opportunities for early detection and prevention. Continued research into the mechanisms and outcomes of displacement is critical for optimizing both anatomical and functional success in retinal detachment surgery.

Purpose of review: Glucagon-like peptide-1 receptor agonists (GLP-1RA) have gained popularity as an antidiabetic and weight loss agent with protective cardiovascular outcomes, but attention to the potential ocular side effects has grown. This review aims to consolidate the existing evidence on the effects of GLP-1RA on conditions such as diabetic retinopathy (DR), nonarteritic ischemic optic neuropathy (NAION), glaucoma, age-related macular degeneration (AMD), idiopathic intracranial hypertension (IIH), and dry eye disease (DED).

Recent findings: The effect of GLP-1RA on DR is controversial but likely linked to rapid correction of hemoglobin A1c levels. GLP-1RA may be associated with increased risk of NAION, although the mechanism remains elusive. Protective effects have been shown against glaucoma, AMD, and DED possibly due to its anti-inflammatory properties, and these medications may decrease intracranial pressure in IIH.

Summary: As the usage of GLP-1RA increases, further dedicated ocular safety trials are key to determining the risk of eye-related complications. Given the limited prospective evidence available and the proven systemic benefits of the medication, as well as its potential protective effects on certain eye diseases, GLP-1RA use should generally not be discouraged in most patients. Regular ophthalmologic follow up is important in patients considered at higher risk of ocular adverse events.

Purpose of review: The management of retinoblastoma is an evolving field, with ongoing research focused on novel diagnostic techniques and therapeutic interventions. This review aims to summarize the current treatment options for retinoblastoma and explore future directions in the field.

Recent findings: Early diagnosis remains crucial for improving prognosis in retinoblastoma, as prompt identification significantly enhances treatment success. New diagnostic imaging strategies as well as prenatal testing are being developed to detect subclinical disease in high-risk patients, allowing for earlier intervention. Recurrent or refractory disease remains a challenge, but encouraging results have been observed with intravenous chemotherapy, intra-arterial chemotherapy, and intravitreal chemotherapy as salvage therapies. Other strategies, including anterior chamber chemotherapy, novel drug formulations, and advanced delivery methods like sustained release chemotherapy in the form of a chemoplaque, are being explored to address these persistent challenges.

Summary: Significant progress in retinoblastoma treatment has led to a dramatic improvement in globe salvage rates. Nevertheless, challenges remain. Delayed diagnosis, particularly in low-income and middle-income regions, continues to contribute to reduced survival rates. Additionally, the management of advanced disease, as well as recurrent or refractory tumors, remain critical issues. The development of new drugs and delivery methods as well as modified treatment strategies offer promise in overcoming these obstacles.

Purpose of review: As the prevalence of cataracts continues to rise, the increasing demand for cataract surgery may surpass the availability of ophthalmologists. This review examines the role of optometry in the co-management of patients with cataracts, including preoperative and postoperative care, and discusses the implications of expanding optometric scope-of-practice laws.

Recent findings: Collaboration between optometrists and ophthalmologists occurs through two primary models: referral-based and integrated management. Studies indicate that direct referrals from optometrists to ophthalmologists improve surgical listing rates and streamline patient care. Integrated models enhance efficiency by incorporating optometrists into ophthalmology practices, allowing ophthalmologists to focus on surgical interventions. Postoperative care co-managed by optometrists has demonstrated mostly favorable visual outcomes, with 86% of patients achieving 20/40 vision or better and low postoperative complication rates. However, legislative changes expanding optometric surgical privileges remain controversial due to concerns about training adequacy and patient safety. Sharing clinical responsibilities can lead to a "slippery slope" phenomenon encroaching on the surgeon's role and threatening patient care.

Summary: Optometry-ophthalmology co-management can enhance surgical efficiency, improve patient access, and alleviate workforce shortages. While co-management may be effective for routine cases, the expansion of optometric surgical privileges raises debate regarding clinical competency and regulatory oversight. Future efforts should focus on creating best practice guidelines for standardizing training, shared ethical responsibility, and ensuring high-quality, patient-centered care.