Clinical ophthalmology (Auckland, N.Z.)最新文献

Introduction: Macular atrophy represents an end-stage of myopic maculopathy. This study aims to identify predictive factors for atrophy growth in patients with treated myopic macular neovascularization (mMNV).

Methods: Retrospective study including 98 eyes from 83 patients registered in the national database of retinal diseases and followed and treated for mMNV for at least 2-years at our tertiary center. Our primary outcomes were the increase in the chorioretinal atrophic area (CRA) and final best corrected visual acuity (fBCVA).

Results: Most patients (n=55, 56.1%) successfully stopped treatment after 3+pro re nata (3+PRN) (mean 6.8±5.3 intravitreal injections, IVI), while 27 patients (27.6%) required uninterrupted treat and extend (T&E) regimen (mean 27±15.46 IVI). BCVA improved from 47.18±23.06 to 58.66±21.27 ETDRS letters after mMNV treatment, over a mean of 6.04±4.1 years [2-15]. There was a 16.9% larger final mean CRA and a mean growth of 0.48±1.17mm²/year, significantly associated with worse fBCVA in the subfoveal atrophy group (39.10±28.08, p<0.001) and negatively correlated with the initial subfoveal choroidal thickness (SCT) (r=-0.31, p=0.004). The baseline CRA was the major determinant of a larger final CRA (β=0.90, p<0.001). Patients under uninterrupted T&E showed a higher CRA growth rate (0.95±1.87mm²/year, p=0.0076).

Conclusion: Macular atrophy after mMNV leads to irreversible visual loss. The baseline atrophic area predicts final macular atrophy. Initial SCT and the implemented treatment regimen (especially with a higher number of IVI) influence atrophy growth, although not significant in the multivariable model.

Purpose: To compare twelve-month visual, anatomical, safety, and inflammation-biomarker outcomes of intravitreal dexamethasone implant (DEX) in treatment-naïve versus recalcitrant center-involving diabetic macular edema (CI-DME) eyes.

Patients and methods: In this multicenter, retrospective cohort study (January 2022 to December 2024) at two Indian tertiary centers, adults with type 2 diabetes and CI-DME confirmed by optical coherence tomography (OCT) were stratified into treatment-naïve or recalcitrant cohorts. All eyes received a 0.7 mg dexamethasone implant, with pro-re-nata retreatment for recurrent fluid, ≥5-letter best-corrected visual acuity (BCVA) loss, or ≥50 µm central macular thickness (CMT) increase. Visits at baseline and periodic intervals up to 12 months included BCVA, intraocular pressure (IOP), slit-lamp and fundus exams, and OCT quantification of CMT and presence and/or hyperreflective foci (HRF). Safety and adverse event monitoring included IOP elevations, cataract progression, and other ocular adverse events. Statistical analysis used paired and independent tests with P < 0.05.

Results: We analyzed 102 eyes (30 naïve, 72 recalcitrant) from 74 patients (mean age 61.7 ± 8.8 years). Mean DEX implants per eye were 1.83 ± 0.73, higher in recalcitrant eyes (1.87 vs 1.73; P = 0.02). At 12 months, mean BCVA improved from 0.73 ± 0.26 to 0.62 ± 0.28 logMAR (P = 0.002), with no intergroup differences (P > 0.05). Mean CMT decreased from 520 ± 144 to 462 ± 192 µm (P = 0.03), similarly across cohorts (P > 0.10). HRF declined from 58% to 26% (P < 0.001). Ocular adverse events included cataract progression in 39% of phakic eyes (26% underwent surgery) and transient IOP elevations >21 mmHg in 9.8%, all managed medically; no glaucoma surgery was required.

Conclusion: In real-world practice, intravitreal DEX implant delivers sustained visual and anatomical benefits in both treatment-naïve and recalcitrant CI-DME eyes. Although cataract progression and transient IOP rises occur, they are predictably manageable. Its extended durability and acceptable safety profile underscore DEX implant as a practical, valuable option across diverse DME populations.

Objective: Hemophagocytic lymphohistiocytosis (HLH) associated retinopathy remains poorly characterized in terms of clinical phenotypes and pathogenesis. This retrospective study aimed to systematically define the multimodal imaging features of retinal lesions in patients with HLH and investigate its underlying pathological mechanisms to inform clinical practice.

Methods: A retrospective case series analysis was conducted on 15 HLH patients with retinal lesions. Comprehensive ophthalmic evaluations, including fundoscopy and optical coherence tomography (OCT), were integrated with systemic multimodal imaging data.

Results: Imaging analysis revealed characteristic retinal structural alterations, including retinal hemorrhage (26 eyes, 86.67%), outer retinal atrophy (20 eyes, 66.67%), outer retinal hyperreflective foci (7 eyes, 23.33%), ellipsoid zone disruption (17 eyes, 56.67%) and ellipsoid zone thinning (10 eyes, 33.33%). Multimodal imaging findings suggest a potential association between HLH related retinopathy and a hypoperfused ischemic state of the retina, though this requires further validation through larger scale statistical analysis. Notably, characteristic damage to the outer retinal structures was observed across HLH patients of different etiological subtypes and could manifest at any stage of the disease, including before and after interventions such as chemotherapy and hematopoietic stem cell transplantation.

Discussion: The study data indicate potential involvement of HLH induced systemic cytokine storms, secondary hemoglobin reduction, and hematologic abnormalities such as thrombocytopenia in the observed retinal changes. These interpretations should be understood as hypothesis generating observations within the constraints of descriptive research methodology. Therefore, while cytokine cascade control remains a cornerstone of management, future studies should explore the potential benefit of blood component supplementation as an adjunctive therapy in HLH related retinopathy.

Conclusion: These findings highlight the necessity of establishing early warning indicators for HLH associated retinopathy and conducting multicenter prospective studies to optimize evidence based diagnostic and therapeutic strategies.

Background: The aim of this study was to evaluate the long-term in vivo positional stability of a novel suprachoroidal telemetric intraocular pressure (IOP) sensor implant.

Methods: In this prospective, open-label, multicenter interventional study, 24 patients undergoing nonpenetrating glaucoma surgery with simultaneous implantation of the suprachoroidal EyeMate-SC IOP sensor were considered (Implandata Ophthalmic Products GmbH, Hannover, Germany). Overall, 11 patients were excluded owing to incomplete data. Of the remaining patients, 11 were diagnosed with primary open-angle glaucoma, 1 with pseudoexfoliative glaucoma, and 1 with uveitic glaucoma. The sensor position was measured intraoperatively via surgical video analysis and postoperatively via swept-source anterior segment optical coherence tomography (Anterion, Heidelberg Engineering GmbH, Heidelberg, Germany) with reference to the anatomical limbus. Postoperative assessments were conducted at 10, 30, 90, 180, 270, 360, 540, 720, 900, and 1080 days.

Results: Unilateral implantation was successful in all 24 cases. No dislocations occurred. In one patient, partial suprachoroidal positioning was observed intraoperatively, with subsequent autonomous repositioning into full suprachoroidal placement within weeks. Excluding this case, the absolute implant position was 1.6 ± 0.8 mm at day 0, 1.7 ± 1.0 mm at day 360, 1.9 ± 1.8 mm at day 720, and 2.1 ± 0.9 mm at day 1080. Notably, the relationship between ΔIOP (Goldmann applanation tonometry - EyeMate-SC reading) and absolute implant position remained nonsignificant, regardless of whether the patient with the initially incomplete implantation was included (r = -0.08, 95% CI: -0.32 to 0.38) or excluded (r = -0.11, 95% CI: -0.37 to 0.36).

Conclusion: This study indicates high long-term in vivo positional stability of the EyeMate-SC IOP sensor. The observed variations were within measurement uncertainty. This supports the sensor's potential for safe and continuous IOP monitoring in glaucoma care.

Purpose: To compare operating room (OR) utilization time between immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) at a tertiary care hospital in Thailand.

Patients and methods: This prospective observational study was conducted at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. From April to September 2024, a total of 99 patients were recruited (45 ISBCS, 54 DSBCS). Nine DSBCS patients were excluded due to surgery intervals exceeding 12 weeks, resulting in 90 patients (45 per group) for analysis. Inverse probability of treatment weighting (IPTW) was applied to balance baseline covariates. Weighted linear regression models were used to estimate treatment effects on total OR time and its components, including preparation, draping, surgical, exit, and turnover times.

Results: Baseline characteristics showed ISBCS group had more surgeries performed by younger surgeons (p = 0.014) and more frequent use of toric (p = 0.034) and preloaded IOLs (p = 0.004). Average OR utilization time was 55.8 minutes (SD = 12.0) for ISBCS and 60.0 minutes (SD = 12.9) for DSBCS. After IPTW adjustment, ISBCS reduced total OR time by 5.81 minutes (95% CI 0.87 to 10.76) compared to DSBCS. This reduction remained consistent across multivariate models (5.86-5.99 minutes). Time savings were primarily attributed to shorter surgical time (p = 0.006), exit time (p < 0.001), and turnover times (p = 0.002). Surgeon experience had the most significant impact on OR time.

Conclusion: ISBCS reduced total OR utilization time by approximately 6 minutes (10%) per patient compared to DSBCS, enhancing operational efficiency and potentially increasing surgical capacity.

Purpose: Minimally invasive nasal trabeculostomy (MINT™) is an ab interno, stent-less, trabecular-opening glaucoma procedure designed to reduce intraocular pressure (IOP) in patients with open-angle glaucoma (OAG). This 12-month, prospective, single-arm, open-label study aimed to evaluate the performance and safety of the MINT device in patients with OAG with uncontrolled IOP.

Methods: Eligible patients had uncontrolled OAG (IOP ≥21 mmHg with maximum tolerated glaucoma medications). The primary efficacy endpoint was the proportion of patients achieving ≥20% IOP reduction from baseline on the same or fewer medications at Week 24. Secondary efficacy endpoints were mean change in IOP from baseline at Weeks 24 and 52, and the proportion of patients achieving a ≥20% reduction in IOP from baseline on the same number or fewer medications at Week 52.

Results: The procedures were performed between 11 April 2022 and 24 October 2022 by one surgeon (LV) at the Ophthalmologic Center after S.V. Malayan, Yerevan, Armenia. Sixty-six eyes of 66 patients underwent the procedure; 63 and 56 patients completed the Week 24 and 52 visits, respectively. Fifty-two of 63 (82.5%) patients achieved the primary endpoint. The mean (standard deviation) baseline IOP (22.7 ± 1.4 mmHg) was reduced by 34.2% to 15.0 ± 2.8 mmHg at Week 24, and by 35.3% to 14.7 ± 2.4 mmHg at Week 52. Twenty-two adverse events (AEs) were reported, including 20 postoperative ocular AEs in 15 patients. Ocular AEs were non-serious and mild.

Conclusion: In this patient population, the MINT device achieved an 82.5% success rate as per the FDA-recommended primary endpoint. IOP was lowered from baseline, below the European Glaucoma Society target range for early glaucoma (<20 mmHg) in 98.4% of patients and moderate glaucoma (<17 mmHg) in 68.3% of patients. No intraoperative and minimal postoperative complications were reported.

Clinical trial registration: https://clinicaltrials.gov/study/NCT05638906 (NCT05638906).

Pythium insidiosum keratitis is a vision-threatening corneal infection that often mimics fungal keratitis, yet it responds poorly to standard antifungals. Historically, approximately 80% of cases have required surgical excision of the cornea. Unlike fungi, P. insidiosum lacks ergosterol in its cell membrane and possesses a cellulose-rich wall with minimal β-1,3-glucan exposure, reducing Dectin-1-mediated detection. Surface hydroxyproline-rich glycoproteins structurally resemble host collagen, potentially engaging inhibitory lectin receptors and dampening early innate immune responses. Delayed Toll-like receptor (TLR4) activation, limited TLR2 signaling, and altered complement activation contribute to subdued inflammatory recruitment, allowing the pathogen to establish deep stromal infection before overt clinical signs emerge. We hypothesize that the organism's aggressive behaviour stems from immune camouflage. P. insidiosum evades early host immune detection by masking its pathogen-associated molecular patterns (PAMPs) and mimicking host molecules. This allows the oomycete to establish infection with minimal initial inflammation. Supporting evidence includes the atypical, cellulose-rich cell wall (with minimal β-glucan and no ergosterol) of P. insidiosum blunts early cytokine responses. Moreover, the corneal cells infected with Pythium initially produce very low levels of IL-1β, underscoring the potential need for adjunctive immunotherapies to effectively clear the infection. If validated, this immuno-evasion hypothesis has major implications: diagnostic assays could incorporate host immune response patterns, and novel treatments might combine cell wall-degrading enzymes or Pattern Recognition Receptor (PRR) agonists with immunotherapy to "unmask" the pathogen for immune elimination. Ultimately, viewing P. insidiosum as an immuno-camouflaged pathogen offers a new paradigm to explain its clinical course and to improve outcomes in this often-devastating keratitis.

Purpose: To evaluate binocular distance-target corrected (DC) near vision in patients having bilateral implantation of Clareon Vivity and Clareon Vivity Toric IOLs (Alcon Vision, LLC) targeted for mini-monovision, with the dominant eye set at emmetropia and the non-dominant eye at -0.50 D.

Patients and methods: A prospective, unmasked single-armed observational study of 25 adult patients undergoing bilateral Clareon Vivity IOL with mini-monovision. Binocular uncorrected (U) and DC visual acuity (VA) at distance (6 m), intermediate (66 cm), and near (40 cm); mean refractive spherical equivalent (MRSE) for each eye and difference between contralateral eyes; binocular uncorrected reading performance using MNRead; and patient reported outcomes using the PRO Questionnaire (Research Insight, LLC) were collected at 3 months postoperatively. The primary outcome was proportion of subjects achieving DCNVA 20/32 or better.

Results: Mean MRSE was -0.17 and -0.49 D for dominant and non-dominant eyes at 3 months. 88% of subjects met the primary endpoint of DCNVA ≥ 20/32. MNRead testing showed a mean reading acuity of 0.12 logMAR, critical print size of 0.31 logMAR, and maximum reading speed of 144.78 wpm. 87.5% of subjects had little to no visual disturbances. 66.7% of patients reported occasional to no use of reading glasses. 95.8% patients were satisfied with their vision after surgery.

Conclusion: Bilateral implantation of Clareon Vivity lenses with a mini-monovision approach achieved good visual performance with low levels of visual disturbances and a high level of patient satisfaction. The majority of subjects were spectacle independent and reading performance was near normal for their age without correction.

Pythium insidiosum keratitis is an aggressive, vision-threatening corneal infection increasingly recognized across India, particularly among agricultural workers during monsoon season. Frequently misclassified as fungal keratitis, it responds poorly to conventional antifungals because the oomycete has a cellulose- and β-glucan-rich wall and lacks ergosterol, leading to therapeutic delay and rapid stromal melt. Indian cohorts have refined a practical diagnostic signature such as tentacular or reticular peripheral infiltrates with guttering, early endothelial plaque and hypopyon, and minimal satellite lesions. Calcofluor white and KOH show broad, ribbon-like, sparsely septate filaments; blood agar often grows colonies while Sabouraud shows scant growth; IVCM reveals thin, linear, right-angle branching hyphae; and PCR/ITS sequencing confirms species. Emerging immunology indicates early evasion of pattern-recognition receptors (TLR/CLR pathways) followed by dysregulated neutrophilic inflammation that accelerates collagenolysis. Management in India has converged on a surgery-first bias for deep or progressive disease early therapeutic keratoplasty with wide margins combined with targeted medical therapy: topical linezolid 0.2% and azithromycin 1% (± minocycline systemically), aggressive lubrication, and stromal melt mitigation (oral doxycycline, cautious steroids only post-control). Adjuncts include cyanoacrylate for impending perforation and intracameral/ intrastromal antibiotics in selected cases. Outcomes improve with rapid organism-specific therapy, meticulous peri-operative planning, and vigilant recurrence surveillance. India's experience underscores priorities for the next decade: point-of-care diagnostics (LAMP/CRISPR), standardized drug susceptibility platforms, optimized peri-keratoplasty protocols, and host-directed immunomodulation to temper destructive inflammation without impairing clearance. This review synthesizes epidemiology, clinical diagnostics, immunopathogenesis, and management, translating India-derived insights into a pragmatic framework for regions confronting the global spread of Pythium keratitis.