BMJ Open Ophthalmology最新文献

Purpose: Some patients with neovascular age-related macular degeneration (nAMD) have persistent signs of exudation under treatment with intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents. We examined the real-world anatomical responses among patients with suboptimal response and switched to faricimab using artificial intelligence (AI)-based retinal fluid quantification.

Methods: A retrospective, multicentric, cohort study of patients in France with exudative signs and switched to faricimab without a new loading phase, maintaining the same prior injection interval. The RetInSight Fluid Monitor AI software quantified subretinal (SRF) and intraretinal (IRF) fluid on spectral domain optical coherence tomography. The primary outcome was change in SRF and IRF volumes in the central 1 and 6 mm retinal areas after one and two injections of faricimab.

Results: 74 patients (74 eyes) were included (mean age: 81.5±8.4 years, 49% male). Significant reductions were observed in mean 1 mm IRF (-2.9±18.3 nl; p=0.002), mean 6 mm IRF (-17.7±71.1 nl; p<0.001) and mean 6 mm SRF (-24.8±156.3 nl; p<0.001) volumes after one injection. The proportion of dry eyes (<5 nl for SRF and IRF in the 1 and 6 mm areas) increased from 0% at baseline to 32.4% after one injection and 48.4% after two injections. Lower baseline SRF volumes were predictive of dry response after one injection (_adjOR 0.965; p=0.028) and lower baseline IRF volumes were predictive of dry response after two injections (_adjOR 0.373; p=0.051).

Conclusion: Nearly half of patients achieved a dry response after two injections. AI-assisted fluid quantification provided objective monitoring, identifying lower baseline SRF and IRF as predictive factors for good response. Limited patient inclusion means longer-term and larger prospective studies are now required using automated retinal fluid quantification to further refine the baseline characteristics of good switch responders to better adapt switch protocols.

Background: Diabetic retinopathy (DR), a microvascular complication of diabetes mellitus (DM), is a leading cause of vision loss worldwide. There is limited national data to inform about the prevalence of DM and DR and its associated factors, which led to the basis of conducting this survey, which would guide us for the same as part of the Rapid Assessment of Avoidable Blindness (RAAB) survey conducted across Nepal.

Methods: A population-based cross-sectional RAAB survey was conducted using multistage cluster random sampling. RAAB+DR methodology was conducted between June 2019 and February 2021 among individuals aged≥50 years across selected provinces. Diabetes was diagnosed based on treatment history and random blood glucose test with level>200 mg/dL, while DR was graded by trained ophthalmologists. All relevant data were imported into the RAAB software to determine the prevalence of DM, DR and associated factors.

Results: Among the 13 510 participants examined, the prevalence of DM was found to be 6.1% which was higher in Bagmati province at 9.4% (95% CI: 8.2% to 10.7%). Prevalence of DM was higher among females, but DR was more common in males in rural areas and females in urban areas. Untreated diabetes was most common in Madhesh (35.1%). DR prevalence was highest in Bagmati (15.9%; 95% CI: 12.7% to 19.1%), and 2.5% (95% CI: 1.2% to 3.8%) of those patients had sight-threatening DR. In Bagmati, 24.1% of diabetics had never undergone an eye examination.

Conclusion: The limited coverage of DR screening underscores the need for enhanced community-based DR screening and referral programmes. Our study lacked the use of plasma blood glucose level measurement to diagnose DM, proper slit lamp examination for diabetic retinopathy grading and diagnosis, and inclusion of a younger population providing a better representation. Strengthening these initiatives can prevent vision-threatening complications in underserved populations.

Objective: Retinoblastoma is the most common paediatric intraocular malignancy, originating in neural retina germ cells. Early diagnosis is crucial for survival and eye preservation. This study analyses gene expression and specific microRNAs (miRNAs) in patients with retinoblastoma to enhance early diagnosis, prognosis and treatment strategies.

Methods: This study examined gene and miRNA expression in 18 patients with retinoblastoma and 10 healthy individuals. Peripheral blood samples were collected from all participants, and patient demographics were recorded. The analysis was performed using real-time PCR targeting the RB1 and N-MYC genes, along with the miRNAs miR-125-5p, miR-221-3p and miR-519-3p.

Results: The patient group consisted of 18 participants (9 males, 9 females), aged between 2 and 6 years (mean±SD: 4.8±1.33 years), with a mean diagnosis age of 3.01±1.37 years. All participants were followed for 3 years, with no fatalities. The control group comprised 10 participants (4 males, 6 females), aged 2-8 years (mean±SD: 5.01±1.77 years). 11 patients underwent enucleation due to tumour progression: 3 right eyes and 8 left eyes. Gene expression analysis showed significant downregulation of miR-125-5p, miR-519-3p and NMYC in the retinoblastoma group. RB1 downregulation and miR-221-3p upregulation were noted in most patients, but without significant associations.

Conclusion: miRNAs, along with RB1 and N-MYC genes, may serve as predictive and prognostic biomarkers in retinoblastoma. While previous studies have highlighted the impact of certain miRNAs on survival and clinical outcomes, our study is limited by a small sample size and lack of strong statistical correlations. Large-scale studies are needed to validate these preliminary findings and clarify their clinical significance. Understanding the role of miRNAs in cancer biology could improve retinoblastoma mechanism insights and patient care.

Objective: Early identification of cerebral visual impairment (CVI) is important in providing timely educational support. This study explores the feasibility of early years teachers (EYT) administering in-nursery assessments of visual function.

Methods and analysis: EYT within six nursery settings were recruited and underwent training and supervision in visual acuity and tablet-delivered visuoperceptual testing (children's visual impairment test; CVIT 3-6). Binocular visual acuity was recorded at 1.5 m and 33 cm. A crowding ratio was calculated if visual acuity was poorer than 0.3 logMAR. Engagement scores were completed to offer insights into areas of testing children found easiest/hardest to engage with.

Results: Four nursery settings completed training and the families of 37 children aged 3-4 years consented to participate; 97% of participants completed acuity testing (mean testing time 5 min) and 86% participants underwent CVIT 3-6 testing (mean testing time 15 min). Mean CVIT 3-6 score was 54.6/70, (expected 10th centile score for age=53). Only 55% children completed all 14 CVIT 3-6 domains. The subtests with poor performance in all three areas (pass rate, completion rate and engagement score) were 'structure from motion', 'missing part' and 'coherent motion'.

Conclusion: Training EYT to administer visual function testing is feasible, in that some elements can be conducted in all children with a reasonably short test time. Further studies are required to identify which visuoperceptual testing domains offer the highest sensitivity/specificity for CVI-related visual dysfunction in this age group.

Objective: Optometric practices increasingly use ocular imaging as part of routine eye care. Alongside the increase in e-referral systems, the use of such images provides an opportunity for more accurate triaging of referrals, to ensure the most appropriate use of limited hospital resources. To encourage the incorporation of images into anterior eye pathology referrals, an NHS commissioner for Calderdale and Kirklees (West Yorkshire, UK) provided slit lamp mountable cameras to 20 local optometric practices. This study qualitatively explored the outcomes from this pilot study, identifying barriers and enablers for incorporating similar technology more widely.

Methods and analysis: Six months after receiving the camera, participating optometrists were contacted to discuss their experiences via semi-structured interviews. Opinions were also sought from commissioners of the initiative. Transcripts were reviewed and coded by the research team and organised via thematic analysis.

Results: Twelve semi-structured interviews took place. Five themes were identified: practice autonomy, communication, financial and time costs, hardware and software issues, and wider application of technology. Practitioners typically reported that the device had not been used much. This was partly due to difficulties integrating the device into their routine practice and partly due to the relatively low prevalence of anterior eye pathology requiring referral. A wider remit for the technology, other than simply improving triaging efficiencies, was also identified as part of this study.

Conclusion: This study highlights the importance of conducting small pilot studies prior to significant investment of scarce NHS resources. It also highlights the importance of sharing negative findings to share best practice and avoid wastage. Limitations of this investigation included the voluntary approach of both the camera scheme and our interviews; practitioners who took part in the study were more likely to be engaged and to participate in these types of schemes compared with non-participating practitioners, and the study was unable to investigate the barriers to entry for non-participants. Nevertheless, consulting with local practitioners during service design for similar new schemes may pre-empt potential barriers and facilitate greater engagement and practice autonomy for future schemes.

Objective: This study evaluated the clinical characteristics and treatment outcomes of bigger premature infants treated for retinopathy of prematurity (ROP).

Methods: A retrospective, multicentre study analysed data from 33 ROP centres in Türkiye. Infants with gestational ages (GA) of 32-37 weeks and birth weights (BW) >1500 g who required ROP treatment were included. Patient demographics, clinical details, treatments, responses and complications were recorded. Descriptive statistics were calculated after excluding cases with missing or erroneous data.

Results: The study included 365 eyes of 365 infants. The average GA at birth was 33±1 weeks, with a mean BW of 1896±316 g. Of these, 83.6% had type 1 ROP, and 16.4% had aggressive ROP (A-ROP). Treatment-requiring ROP (TR-ROP) occurred at an average postmenstrual age of 39.0±4.6 weeks. Among 170 infants with TR-ROP at their first exam, 81.2% were screened at 4 weeks postpartum. Reactivation of ROP was observed in 5.4% of the primary laser photocoagulation (LPC) group and 23.9% of the primary anti-vascular endothelial growth factor (VEGF) group (p<0.001). Reactivation and progression to stage 4-5 were more frequent in A-ROP cases (p=0.012; p=0.008). The need for additional treatment was significantly higher in cases of A-ROP, zone 1 disease or stage 4-5 disease (p<0.001). Anti-VEGF therapy demonstrated superior single-treatment success rates in A-ROP eyes compared with laser LPC (85.7% vs 60%, p=0.03). Infants requiring additional treatments also had higher rates of respiratory distress syndrome (RDS), maternal premature rupture of membranes (PROM) and non-ophthalmological surgical interventions (p<0.05).

Conclusion: Bigger premature infants in low and middle-income countries should be screened earlier than 4 weeks after birth. A-ROP, zone 1 disease and stage 4-5 disease have higher reactivation risks. Primary anti-VEGF therapy was associated with a greater need for retreatment. Maternal PROM, RDS and surgical interventions also increase retreatment risk. Limitations include retrospective design and lack of smaller preterm comparisons, potentially limiting generalisability.

Objective: Photoreceptors can be impacted early in diabetes mellitus (DM). The primary goal of this study was to determine if having DM and no/mild diabetic retinopathy (DR) affected photoreceptor layer thickness.

Methods and analysis: Participants from the UK Biobank database who underwent fundus photographs and macula-centred spectral domain-optical coherence tomography were considered for inclusion in the study. Multivariable linear regression models were used to compare photoreceptor thickness between participants with DM (no/mild DR) and without DM after adjusting for confounders. Secondary analyses investigated factors associated with photoreceptor thickness among participants with DM (no/mild DR).

Results: 64 237 participants without DM and 3832 with DM were included. Among those with DM, 2683 had no/mild DR. The inner segment/outer segment (IS/OS) photoreceptor junction was significantly thinner in participants with DM (no/mild DR) compared with those without DM (-0.06 µm, 95% CI -0.10 to -0.03). The OS photoreceptor layer was thinner in participants with DM (no/mild DR) compared with those without DM (-0.14 µm, 95% CI -0.19 to -0.08). Among participants with DM (no/mild DR), being male was associated with thinner IS/OS (p<0.001) and higher A1c level was associated with thinner OS (p=0.02). Thicker OS layer was associated with higher high-density lipoprotein (p<0.001), male gender (p<0.001) and higher spherical equivalent (p=0.005).

Conclusions: We found photoreceptor layers to be thinner in participants with DM (no/mild DR) compared with those without DM. Limitations include the absence of additional imaging such as angiography to evaluate the retina for early vascular changes or choroidal imaging to study the potential impact of the choroid on photoreceptors. Overall, our findings suggest that changes in photoreceptors may occur prior to evidence of more than mild DR on fundus photographs.

Objective: To determine the prevalence and risk factors for blindness at initial hospitalisation with primary angle-closure glaucoma (PACG) and proposed glaucoma surgery in China.

Methods: A multistage stratified sampling method was used to select patients with PACG (1 January 2011 to 31 December 2020) presenting for initial hospitalisation from hospitals of various levels (n=26): 2 nationally leading ophthalmic hospitals, 12 university-affiliated and provincial people's hospitals and 12 city-level hospitals. Blindness is defined according to WHO standards, with visual acuity <3/60 defined as blindness. We used separate logistic regression models to identify the risk factors for blindness in at least one eye and bilateral blindness.

Results: Among the 3957 patients with PACG included in this study, 42.7% (n=1691) and 5.33% (n=211) had either-eye and bilateral blindness, respectively. In multivariable logistic models, participants with 60-69 years (ORs=1.28, 95% CI 1.06 to 1.55), 70-79 years (OR=2.27, 95% CI 1.85 to 2.78) and >80 years (OR=4.21, 95% CI 3.09 to 5.73) had a higher risk of either-eye blindness compared with those aged 50-59, higher intraocular pressure (IOP; OR=1.06 per mm Hg, 95% CI 1.05 to 1.07), residence in rural areas (OR=1.45, 95% CI 1.24 to 1.70) and presentation to city-level hospitals (vs higher-level facilities, OR=1.53, 95% CI 1.18 to 2.00) increased risk. Similar results were obtained for bilateral blindness.

Conclusions: In China, two out of every five PACG patients presenting for initial hospitalisation experienced blindness in at least one eye. Efforts to reduce this burden should focus on improving diagnostic and treatment services at city-level facilities in rural settings while focusing on older patients presenting with higher IOP.

Purpose: Age-related macular degeneration (AMD) remains the leading cause of blindness in developed countries. There are many different intravitreal anti-vascular endothelial growth factor (VEGF) drugs available for the treatment of neovascular AMD (nAMD). Unfortunately, not all patients respond equally well to the drugs, and some show recurrences during treatment. Since 01/2024, aflibercept 8 mg represents an additional treatment option and contains a four times higher dosage than the already known aflibercept 2 mg.

Methods: To evaluate the real-world efficacy of aflibercept 8 mg in refractory nAMD patients, focusing on changes in key optical coherence tomography biomarkers over a follow-up period of the first four aflibercept 8 mg injections using a deep learning-based semantic segmentation algorithm. Inclusion criteria were: switch to aflibercept 8 mg after insufficient response to aflibercept 2 mg, marked by persistent retinal fluid or inability to extend treatment beyond 6 weeks; completion of at least 3 months (90 days) follow-up under treat-and-extend treatment regime; and no confounding conditions like intraocular infection, uveitis or other retinal diseases.

Results: 23 eyes of 21 patients with therapy-resistant nAMD were switched to aflibercept 8 mg. All patients had previously received aflibercept 2 mg, with an average of 30.7 previous anti-VEGF injections. Significant reductions in intraretinal fluid and fibrovascular pigment epithelial detachment at timepoint V3 were observed. The decrease in subretinal fluid and central retinal thickness at V3 was not significant. Treatment intervals extended significantly by 24%, from a baseline average of 34 days to 42 days. Best-corrected visual acuity remained stable throughout the study period.

Conclusions: Aflibercept 8 mg demonstrated significant efficacy and durability in reducing nAMD biomarkers and extending intervals in a real-world setting. The use of deep learning for biomarker quantification highlighted its potential for enhancing treatment monitoring and decision-making. Future studies with a larger patient cohort and prospective study setting should explore long-term outcomes and integration of artificial intelligence-driven analysis.