Current Opinion in Ophthalmology最新文献

Purpose of review: We summarize evidence-based considerations regarding the use of intracameral antibiotics during cataract surgery.

Recent findings: The use of intraoperative intracameral antibiotics reduced the incidence of postcataract surgery endophthalmitis 3.5-fold, with an odds ratio ranging from 0.14 to 0.19. A survey of the American Society of Cataract and Refractive Surgery showed usage of intracameral injections of antibiotics increased by 16% in the United States between 2014 and 2021. The frequency of vancomycin usage has sharply dropped to 6%, while moxifloxacin is now the dominant choice at 83% among respondents. One analysis showed that 2500 patients need to be treated with intracameral antibiotics to prevent one case of endophthalmitis. A 500 μg intracameral moxifloxacin at $22 dollars per dose is cost-effective, including for patients with posterior capsular rupture (PCR).

Summary: Studies substantiate the safety and efficacy of intracameral antibiotics for endophthalmitis prophylaxis. Intracameral moxifloxacin and cefuroxime are the most common choices. While vancomycin shows potential for efficacy, further studies evaluating clinical outcomes are needed. Adverse events are rare and commonly due to errors in preparation. Topical antibiotics do not provide additional prophylactic benefits to intracameral regimens. Intracameral antibiotics given alone are cost-effective.

Purpose of review: Light adjustable intraocular lens (LAL) is a promising concept in cataract surgery. This review explores considerations for the use of LALs.

Recent findings: Through updates, the safety of LALs and light delivery devices have been enhanced, enabling more efficient treatment with lower ultraviolet (UV) energy. Preoperative topography and aberration are essential for understanding indications for LALs. Furthermore, when determining intraocular lens power, it is crucial to factor in potential postoperative myopia or hyperopic adjustments. This is achieved by establishing a proper postimplantation refractive target and considering potential wavefront changes. Postoperative adjustments for defocus and astigmatism have demonstrated excellent outcomes. Monovision strategy by adjustable blended vision of LALs revealed distance vision of 20/20 along with near vision of J2 in 96% of patients. However, the results of clinical studies on postrefractive cataract surgery showed contrasting outcomes at distance, indicating the need for further research results regarding its effectiveness. A new postoperative workflow needs to be designed to enable a systematic follow-up process.

Summary: LALs are safe and demonstrate promising refractive outcomes. To achieve appropriate results, understanding the changes in optical characteristics associated with adjustment and constructing a new postoperative workflow are necessary.

Purpose of review: Whipple's disease is an infectious cause of uveitis that may present with nonspecific findings of intraocular inflammation, which can precede the development of neurologic symptoms and signs. Whipple's disease, then, may evade consideration in the differential diagnosis for uveitis.

Recent findings: Molecular tests can be helpful in identifying the presence of Tropheryma whipplei from ocular specimens. The application of metagenomic sequencing for ocular specimens is promising, as it offers the opportunity to identify the pathogen when suspicion for an intraocular infection is high. Whipple's disease demonstrates the ability to abrogate the host immune response, which gives some insight into its pathogenesis.

Summary: Whipple's disease should be suspected in patients who have uveitis refractory to anti-inflammatory therapy. Knowledge of this important pathogen can help direct the timely implementation of diagnostic testing.

Purpose of review: The aim of this study to provide an overview of recent publications and opinions in refractive cataract surgery.

Recent findings: With the advent of intraocular lenses (IOLs) on different platforms, the surgeon has a wide arena of types of IOL to choose, depending on the patient's visual requirement. Optimization of the tear film, integrating tomography and topography devices for appropriate keratometry values, biometry, use of advanced formulas for IOL power calculation and application of newer IOLs can help achieve target refraction in cases scheduled for cataract surgery. Intraoperative aberrometry can be a useful aid for cataract surgery in postrefractive cases and can help minimize residual postoperative astigmatism.

Summary: Evolvement and rapid advancement of technology allows to impart desired refractive outcomes in most of the cases postcataract surgery. Appropriate preoperative and intraoperative factors should be considered to achieve the desired postoperative outcome.

Purpose of review: Corneal refractive surgery (CRS) is one of the most popular eye procedures, with more than 40 million cases performed globally. As CRS-treated patients age and develop cataract, the number of cases that require additional preoperative considerations and management will increase around the world. Thus, we provide an up-to-date, concise overview of the considerations and outcomes of cataract surgery in eyes with previous CRS, including surface ablation, laser in-situ keratomileusis (LASIK), and small-incision lenticule extraction (SMILE).

Recent findings: Challenges associated with accurate biometry in eyes with CRS have been mitigated recently through total keratometry, ray tracing, intraoperative aberrometry, and machine learning assisted intraocular lens (IOL) power calculation formulas to improve prediction. Emerging studies have highlighted the superior performance of ray tracing and/or total keratometry-based formulas for IOL power calculation in eyes with previous SMILE. Dry eye remains a common side effect after cataract surgery, especially in eyes with CRS, though the risk appears to be lower after SMILE than LASIK (in the short-term). Recent presbyopia-correcting IOL designs such as extended depth of focus (EDOF) IOLs may be suitable in carefully selected eyes with previous CRS.

Summary: Ophthalmologists will increasingly face challenges associated with the surgical management of cataract in patients with prior CRS. Careful preoperative assessment of the ocular surface, appropriate use of IOL power calculation formulas, and strategies for presbyopia correction are key to achieve good clinical and refractive outcomes and patient satisfaction. Recent advances in CRS techniques, such as SMILE, may pose new challenges for such eyes in the future.

Purpose of review: Options for addressing presbyopia with intraocular lens (IOL) implantation have become more varied and sophisticated. We reviewed recent literature on multifocal and extended depth of focus (EDOF) IOLs in order to provide insight on their respective advantages, with emphasis on the visual outcomes of each design.

Recent findings: Increased patient age, spectral domain optical coherence tomography (SD-OCT) abnormalities, abnormal optical axis measurements, and better preoperative visual acuity have been implicated as predictors of worse postoperative vision or visual quality in multifocal IOLs. Despite differences in objective outcomes, patient-reported outcomes such as satisfaction are consistently similar between multifocal and EDOF IOLs. EDOFs may have slightly lower rates of spectacle independence than trifocals, but there is more support for their use in the setting of with other ocular conditions.

Summary: Multifocal and EDOF IOLs are both viable options for patients who wish to preserve near vision. Given their similar objective performance in many aspects, enabling patients to make informed decisions based on their expectations and visual requirements is critical to postoperative satisfaction. Evidence for advanced technology IOL implantation in pediatric patients remains inconclusive.

Purpose of review: To showcase the majority of online intraocular lens (IOL) calculation tools and highlight some of their characteristics.

Recent findings: Online tools are available for preoperative and postoperative IOL-related calculations, including IOL power and toricity selection for standard patients, patients who underwent prior refractive surgery, keratoconus, limbal relaxing incisions for astigmatism management, realignment of a misplaced or rotated toric IOL, surgical induced astigmatism (SIA), formulae comparison, and other tools.

Summary: As there are new online developments and technology is advancing rapidly, we hope that this review will assist ophthalmologists in becoming acquainted with a large variety of online tools.

Purpose of review: This review aims to clarify the advantages and disadvantages of immediately sequential bilateral cataract surgery (ISBCS) based on recent studies, illustrate the safety of this approach, the cost-effectiveness, and present the importance of inclusion protocols for the best results.

Recent findings: In recent studies, the authors found no evidence of an increased risk of bilateral devastating complications such as endophthalmitis with ISBCS based on descriptive evidence compared to delayed sequential bilateral cataract surgery (DSBCS). Furthermore, recent studies on cost analyses showed that ISBCS resulted in fewer costs and significant cost savings to third-party payers, patients, and society compared to DSBCS.

Summary: The ISBCS surgical approach decreases hospital visits, reduces costs, and provides rapid visual rehabilitation and neuro adaptation. The risk of bilateral simultaneous complications is now recognized to be very rare with intracameral antibiotics and compliance with correct protocols. With new generations of optical biometry and lens calculation formulas, refractive surprises are occasional for normal eyes. However, refractive surprise is controversial, especially in the implantation of presbyopia correction intra-ocular lenses, which must be evaluated carefully in the ISBCS approach.

Purpose of review: Oxidative stress plays a central role in cataract pathogenesis, a leading cause of global blindness. This review delves into the role of oxidative stress in cataract development and key biomarkers - glutathione (GSH), superoxide dismutase (SOD), malondialdehyde (MDA), and 4-hydroxynonenal (4-HNE) - to clarify their functions and potential applications in predictive diagnostics and therapies.

Recent findings: Antioxidants serve as pivotal markers in cataract pathogenesis. GSH affects the central lens due to factors such as enzyme depletion and altered connexin expression, impairing GSH diffusion. Age-related oxidative stress may hinder GSH transport via connexin channels or an internal microcirculation system. N-acetylcysteine, a GSH precursor, shows promise in mitigating lens opacity when applied topically. Additionally, SOD, particularly SOD1, correlates with increased cataract development and gel formulations have exhibited protective effects against posterior subscapular cataracts. Lastly, markers of lipid peroxidation, MDA and 4-HNE, have been shown to reflect disease severity. Studies suggest a potential link between 4-HNE and connexin channel modification, possibly contributing to reduced GSH levels.

Summary: Oxidative stress is a significant contributor to cataract development, underscoring the importance of antioxidants in diagnosis and treatment. Notably, GSH depletion, SOD decline, and lipid peroxidation markers are pivotal factors in cataract pathogenesis, offering promising avenues for both diagnosis and therapeutic intervention.

Purpose of review: Optic neuritis can result from several distinct causes, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody disease (MOGAD), when not idiopathic. This review discusses evidence-based treatment approaches contingent upon each specific cause of optic neuritis.

Recent findings: Current evidence highlights the need for prompt plasmapheresis as adjunct to intravenous methylprednisolone (IVMP) in patients with NMOSD-associated optic neuritis. Recent advances have included a proliferation of novel disease modifying therapies (DMTs) for long-term management of NMOSD and an understanding of how existing therapeutic options can be leveraged to optimally treat MOGAD.

Summary: In acute idiopathic or MS-associated optic neuritis, IVMP hastens visual recovery, though it does not substantially affect final visual outcomes. IVMP and adjunctive plasmapheresis are beneficial in the treatment of NMOSD-associated optic neuritis, with a shorter time-to-treatment associated with a higher likelihood of recovery. The natural history of untreated MOGAD-associated optic neuritis is unclear but treatment with IVMP is near-universal given phenotypic similarities with NMOSD. Long-term immunosuppressive therapy is warranted in patients with NMOSD as well as in patients with MOGAD with poor visual recovery or recurrent attacks.