Baseline characteristics and treatment response predictive of nAMD outcomes with ranibizumab therapy in treatment-naive patients: the RACER subgroup analysis.

BACKGROUND: The Ranibizumab AMD Clinical Efficacy Study (RACER) conducted in treatment-naive adult Taiwanese patients with neovascular age-related macular degeneration (nAMD) suggested the importance of early and intensive dosing of ranibizumab for optimal treatment outcomes. This subgroup analysis aims to provide clinical information on treatment response that can potentially guide on maintaining the treatment or switching anti-VEGF agents in the real-world setting. METHODS: Visual acuity (VA) and central retinal thickness (CRT) were assessed in the RACER subgroup population. Subgroup analysis sets were categorised based on: (1) baseline best-corrected VA (BCVA; ≤ 48 and > 48 letters); (2) baseline CRT (≤ 325 or > 325 µm); and (3) treatment response after three monthly initial injections: < or ≥ 5-letter gain in BCVA and reduction of < or ≥ 50 µm in CRT. RESULTS: Patient age, sex, nAMD duration and number of ranibizumab injections did not differ significantly between the treatment subgroups. Poor baseline BCVA (≤ 48 letters) and baseline CRT severity (> 325 µm) were predictors of maximum BCVA gains (9.6 ± 12.9 letters [95%CI: 6.3 to 12.9] and 5.1 ± 18.3 letters [95%CI: - 0.5 to 10.8] at Months 3 and 12, respectively) and better CRT reductions (- 127.6 ± 104.2 µm and - 104.2 ± 107.4 µm at Months 3 and 12, respectively; both P < 0.001). For the subgroup showing favourable treatment improvement with BCVA gains ≥ 5 letters after three monthly initial injections, 75.6% of patients maintained follow-up at Month 12 with a mean of 6.5 ± 14.3 letter gains (95% CI: 1.2 to 11.7). The BCVA gains < 5-letter subgroup nevertheless had stable BCVA (0.4 ± 12.1 letter gains) and CRT (- 41.9 ± 61.2 µm) at Month 12, respectively. In the subgroup with ≥ 50 µm CRT reduction after three monthly initial injections, there are significantly higher BCVA improvements vs. the < 50 µm CRT reduction subgroup at Month 3 (5.0 ± 8.6 letter gains vs. 1.5 ± 11.6 letter gains, respectively; intergroup P = 0.005). CONCLUSION: Lower baseline BCVA and higher baseline CRT were associated with BCVA gains and CRT reductions throughout the 12-month study period. Early CRT improvements after three monthly initial injections were associated with BCVA gains as early as Month 3.

Easy and Safe Simultaneous Zygoma Reduction and Facelift by Single Incision Through Subcutaneous Approach.

BACKGROUND: The surgery for facelift or zygoma reduction usually has a long operative time, swelling, and blood loss consideration; and therefore, these two procedures are often performed separately. In recent years, an increasing demand for simultaneous zygoma reduction and facelift has been observed; however, few studies have examined safe and effective of simultaneous zygoma reduction and facelift. OBJECTIVE: The aim of this study was to present a safe, easy, and flexible method for combining facelift and zygoma reduction through single facelift incision with minimal blood loss. METHODS: From 2015 to 2020, the senior author performed zygoma reduction with facelift by using a subcutaneous approach through single facelift incision in patients with wide zygoma and an aging face. Operative time, intraoperative blood loss, postoperative course, and complications were recorded. RESULTS: In total, 56 patients met the inclusion criteria and were included in the study. The combined surgery was successfully performed in all cases, and no serious complications were reported. The follow-up period ranged from 6.5 to 60 months. The average operating time was 187 minutes, and the mean intraoperative blood loss was minimal (30 mL). All patients were satisfied with the outcome, different scores were assessed with Global Aesthetic Improvement Scale (GAIS). CONCLUSIONS: Facelift and zygoma reduction using a subcutaneous approach through single facelift incision provides complete visualization of the zygoma, superior hemostasis control, resulting in an easy and safe surgery that does not require additional intraoral incisions.

Refractive outcomes of femtosecond laser-assisted cataract surgery with arcuate keratotomy and standard phacoemulsification with toric intraocular lens implantation.

PURPOSE: Femtosecond laser arcuate keratotomy (FS-AK) and toric intraocular lens (IOL) implantation are effective for the correction of eyes with corneal astigmatism. In this study, the postoperative refractive outcomes of patients receiving femtosecond laser-assisted cataract surgery (FLACS) with FS-AK and patients receiving standard phacoemulsification with toric IOL implantation were evaluated. METHODS: This retrospective study reviewed the postoperative outcomes of patients undergoing FLACS with FS-AK (the FS-AK group) and patients undergoing standard phacoemulsification with toric IOL implantation (the toric IOL group). The main outcome measures were uncorrected and corrected visual acuities, keratometric and refractive astigmatism, and vector analysis. RESULTS: The FS-AK group included 41 eyes with preoperative keratometric astigmatism of - 1.64 ± 0.42 diopters (D), and the toric IOL group included 53 eyes with preoperative keratometric astigmatism of - 2.29 ± 0.91 D (P < 0.001). Postoperative refractive astigmatism was comparable between the two groups. Compared with the FS-AK group, postoperative uncorrected visual acuity was significantly better (P = 0.005) and corrected visual acuity was marginally better in the toric IOL group (P = 0.051). The absolute angles of error were 9.95° ± 9.57° and 5.08° ± 4.94° (P = 0.02) in the FS-AK and the toric IOL groups, respectively. CONCLUSION: Both FLACS with FS-AK and standard phacoemulsification with toric IOL implantation are safe and effective methods for astigmatism correction during cataract surgery. Standard phacoemulsification with toric IOL implantation achieves better visual acuity than FLACS with FS-AK at the 6-month follow-up.

A 12-month, prospective, observational study of ranibizumab in treatment-naïve Taiwanese patients with neovascular age-related macular degeneration: the RACER study.

BACKGROUND: The current National Health Insurance scheme in Taiwan reimburses 3 initial plus 4 additional injections of ranibizumab 0.5 mg for eligible patients with neovascular age-related macular degeneration (nAMD). The Ranibizumab AMD Clinical Efficacy in Real-world practice (RACER) study aimed to observe the effectiveness of ranibizumab injections under this reimbursement system. METHODS: RACER was a 12-month, prospective, observational study conducted in treatment-naïve, adult Taiwanese patients with nAMD. Patients received intravitreal ranibizumab 0.5 mg injections in adherence with local prescribing information. RESULTS: Of 161 patients enrolled, 114 (70.8%) completed the 12-month study. Overall, patients received a mean (standard deviation [SD]) of 4.3 (1.7) ranibizumab injections. The mean (SD, [95% confidence interval], P value) gain in best-corrected visual acuity (BCVA) from baseline at Month 3 was 5.2 (12.2, [3.1, 7.3] letters, P < 0.0001) and at Month 12 was 3.4 (15.4, [0.2-6.6] letters, P = 0.0352). Mean central retinal thickness also decreased from baseline at Months 3 and 12 (both P < 0.001). In subgroup analyses, better treatment outcomes at Months 3 and 12 were observed among patients who received a loading dose and those who had a shorter duration of nAMD at baseline. Adverse events were reported in 58.4% of patients; most (94.4%) were mild-to-moderate in severity and 98.8% were deemed unrelated to study treatment. CONCLUSIONS: Treatment with ranibizumab 0.5 mg resulted in significant improvements in visual outcomes among treatment-naïve Taiwanese patients with nAMD. Early treatment and frequent dosing in the real-world setting may be the key to achieving better outcomes.

Endonasal endoscopic nasolacrimal duct dissection for primary nasolacrimal duct obstruction.

PURPOSE: The purpose of this study is to describe the results of endonasal endoscopic nasolacrimal duct dissection (EE-NLDD); a surgical technique used for the treatment of primary nasolacrimal duct obstruction (NLDO). MATERIALS AND METHODS: Before the operation, the patency of the nasolacrimal duct (NLD) was evaluated through irrigation and probing. The EE-NLDD surgical procedure involved the removal of the bony structure covering the NLD. The NLD mucosa was dissected and marsupialized with nasal mucosa, creating a mucosa-covered ostium. The bone surrounding the lacrimal fossa and lacrimal sac mucosa was preserved throughout procedure. The postoperative anatomical and functional outcomes were evaluated through irrigation, endonasal endoscopic fluorescein dye test, and subjective descriptions of the patients. STUDY DESIGN: This is a retrospective chart review study which included all patients with primary NLDO treated with EE-NLDD surgical technique from February 2012 to July 2016 in Taipei Medical University Shuang Ho Hospital by a single surgeon (YD, Shen). RESULTS: The mean follow-up time for the 39 patients (43 eyes) was 14.7 months (range: 0.5-46 months). Anatomical patency was achieved in all patients. Under endonasal endoscopy, fluorescein dye was observed at the internal orifice after the dye was instilled into the conjunctival sac in all patients. The complete resolution of the epiphora was reported in 36 patients (39 eyes) and two patients (2 eyes) exhibited an improvement of the epiphora after surgery. However, one patient (2 eyes) reported persistent bilateral epiphora without improvement even under solid evidence of anatomical patency. No major complications were noted intraoperatively or postoperatively. CONCLUSIONS: The results suggested that the EE-NLDD is a safe and effective procedure and has a success rate comparable with that of conventional endonasal dacryocystorhinostomy.

Comparison of treatment for congenital nasolacrimal duct obstruction: a systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled trials comparing the success and complication rates among various congenital nasolacrimal duct obstruction (CNLDO) procedures, intervention times, and tubes types. DESIGN: Systematic review with quantitative meta-analysis. METHODS: Studies were identified by searching the PubMed, EMBASE, SCOPUS, and Cochrane databases. The comparisons between categorical variables were analyzed using the χ(2) test, and the dichotomous outcomes were reported as risk ratios. The precision of the effect size was based on the 95% confidence interval. RESULTS: Seven studies published between 2007 and 2013 were included. Immediate versus observation/deferred probing had similar rates of success (82.7% vs 81.8%). Balloon dacryocystoplasty and silicone intubation had similar rates of success (79.8% vs 77.8%). Monocanalicular and bicanalicular intubation had similar rates of success (88.3% vs 88.0%). The dislocation rates for monocanalicular versus bicanalicular intubation were 8.5% and 9.8%, respectively. CONCLUSIONS: Immediate and deferred probing do not differ in their success rates. No difference in success rates was observed between balloon dilation and intubation. Monocanalicular and bicanalicular intubation were similar in their success and dislocation rates. Therefore, the preference of surgeons on the treatment of CNLDO should be discussed with parents to ensure the best possible outcome.

Factors Influencing Intraocular Pressure Changes after Laser In Situ Keratomileusis with Flaps Created by Femtosecond Laser or Mechanical Microkeratome.

The aim of this study is to describe factors that influence the measured intraocular pressure (IOP) change and to develop a predictive model after myopic laser in situ keratomileusis (LASIK) with a femtosecond (FS) laser or a microkeratome (MK). We retrospectively reviewed preoperative, intraoperative, and 12-month postoperative medical records in 2485 eyes of 1309 patients who underwent LASIK with an FS laser or an MK for myopia and myopic astigmatism. Data were extracted, such as preoperative age, sex, IOP, manifest spherical equivalent (MSE), central corneal keratometry (CCK), central corneal thickness (CCT), and intended flap thickness and postoperative IOP (postIOP) at 1, 6 and 12 months. Linear mixed model (LMM) and multivariate linear regression (MLR) method were used for data analysis. In both models, the preoperative CCT and ablation depth had significant effects on predicting IOP changes in the FS and MK groups. The intended flap thickness was a significant predictor only in the FS laser group (P < .0001 in both models). In the FS group, LMM and MLR could respectively explain 47.00% and 18.91% of the variation of postoperative IOP underestimation (R2 = 0.47 and R(2) = 0.1891). In the MK group, LMM and MLR could explain 37.79% and 19.13% of the variation of IOP underestimation (R(2) = 0.3779 and 0.1913 respectively). The best-fit model for prediction of IOP changes was the LMM in LASIK with an FS laser.

Research of electrosurgical unit with novel antiadhesion composite thin film for tumor ablation: Microstructural characteristics, thermal conduction properties, and biological behaviors.

The objective of this study was to use surface functionalization to evaluate the antiadhesion property and thermal injury effects on the liver when using a novel electrosurgical unit with nanostructured-doped diamond-like carbon (DLC-Cu) thin films for tumor ablations. The physical and chemical properties of DLC-Cu thin films were characterized by contact angle goniometer, scanning electron microscope, and transmission electron microscope. Three-dimensional (3D) hepatic models were reconstructed using magnetic resonance imaging to simulate a clinical electrosurgical operation. The results indicated a significant increase of the contact angle on the nanostructured DLC-Cu thin films, and the antiadhesion properties were also observed in an animal model. Furthermore, the surgical temperature in the DLC-Cu electrosurgical unit was found to be significantly lower than the untreated unit when analyzed using 3D models and thermal images. In addition, DLC-Cu electrodes caused a relatively small injury area and lateral thermal effect. The results indicated that the nanostructured DLC-Cu thin film coating reduced excessive thermal injury and tissue adherence effect in the liver.

Retrocaruncular approach for the repair of medial orbital wall fractures: an anatomical and clinical study.

The aim of this article is to investigate a retrocaruncular approach for repairing medial orbital wall fractures. A total of 10 fresh cadaver orbits were dissected to investigate a transconjunctival approach to the orbit posterior to the caruncle. Medical records of consecutive patients with medial orbital wall fractures repaired via a retrocaruncular incision at Wilmer Eye Institute over a 10-year period were retrospectively reviewed. The study was approved by the Johns Hopkins Medical Institution's Institutional Review Board. Feasibility of this approach was clearly demonstrated on all cadavers. Horner muscle was observed to be directly attached to the caruncle and remained undisturbed throughout the retrocaruncular approach. For each of the 174 patients reviewed, this approach allowed successful access to the fracture and proper implant placement. The origin of the inferior oblique muscle was divided in only 19 patients. Sutures were not used for conjunctival incision closure in any patient. For 120 patients who underwent acute repair, the percentage with enophthalmos (≥ 2 mm) decreased from 34% preoperatively to 4% postoperatively; extraocular motility deficit decreased from 41 to 11%. Postoperative complications included recurrence of the preexisting retrobulbar hemorrhage, conjunctival granuloma, and temporary torsional diplopia, each in one patient. The retrocaruncular transconjunctival incision is an effective and safe approach for repairing medial orbital wall fractures with minimal complications. The retrocaruncular incision offers advantages over dividing the caruncle because Horner muscle is left undisturbed, and the incision heals well without suturing.

Glaucoma, Alzheimer's disease, and Parkinson's disease: an 8-year population-based follow-up study.

BACKGROUND: Glaucoma is the leading cause of irreversible blindness worldwide and primary open-angle glaucoma (POAG) is the most common type of glaucoma. An association between POAG and the subsequent risk of Alzheimer's disease (AD) and Parkinson's disease (PD) was unclear. OBJECTIVE: To investigate the association between POAG (including normal-tension glaucoma) and the subsequent risk of AD or PD 8 years following a diagnosis of POAG. METHODS: We performed a retrospective, propensity-score-matched analysis of a population-based cohort consisting of patients with and without POAG aged 60 years and older. Control patients without POAG were propensity-score matched to POAG patients based on their baseline characteristics. RESULTS: The incidence rates and confidence intervals (CIs) of AD among the patients with and without POAG were 2.85 (95% CI: 2.19-3.70) and 1.98 (95% CI: 1.68-2.31) per 1000 person-years, respectively. The incidence rates of PD among the POAG and non-POAG cohorts were 4.36 (95% CI: 3.52-5.39) and 4.37 (95% CI: 3.92-4.86) per 1000 person-years, respectively. Kaplan-Meier failure curves showed that the POAG patients had a higher risk of AD than the control patients did (log-rank test, P= .0189). However, the cumulative PD hazard ratios for the POAG and non-POAG patients did not differ significantly (log-rank test, P= .9953). CONCLUSION: In elderly patients, POAG is a significant predictor of AD, but POAG is not a predictor of PD.

Ophthalmic plastic and orbital surgery in Taiwan.

We describe in this paper the current status of ophthalmic plastic and orbital surgery in Taiwan. Data were collected from the Bureau of National Health Insurance of Taiwan, the Bulletin of the Taiwan Ophthalmic Plastic and Reconstructive Society, and the Statistics Yearbook of Practicing Physicians and Health Care Organizations in Taiwan by the Taiwan Medical Association. We ascertained that 94 ophthalmologists were oculoplastic surgeons and accounted for 5.8% of 1621 ophthalmologists in Taiwan. They had their fellowship training abroad (most ophthalmologists trained in the United States of America) or in Taiwan. All ophthalmologists were well trained and capable of performing major oculoplastic surgeries. The payment rates by our National Health Insurance for oculoplastic and orbital surgeries are relatively low, compared to Medicare payments in the United States. Ophthalmologists should promote the concept that oculoplastic surgeons specialize in periorbital plastic and aesthetic surgeries. However, general ophthalmologists should receive more educational courses on oculoplastic and cosmetic surgery.

Dexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication after pediatric strabismus surgery. Steroids and ondansetron (a 5-HT3 antagonist) can effectively reduce nausea, vomiting, and pain and thus might be useful agents for the prevention of PONV in pediatric patients. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the prophylactic effects of dexamethasone and ondansetron on PONV after strabismus surgery in pediatric patients. METHODS: A comprehensive literature search was conducted to identify RCTs that investigated the efficacy and safety of intravenous dexamethasone or ondansetron on PONV in pediatric strabismus surgical patients. The primary outcome was the incidence of PONV during the initial 24 postoperative hours. The secondary outcomes were number of patients requiring a rescue antiemetic and complications. RESULTS: We included 13 RCTs that evaluated 2006 patients. In the two studies that compared dexamethasone and placebo treatments, POV occurred in 34.3% (23/67) of the patients in the dexamethasone group and in 68.2% (45/66) of the patients in the placebo group. The difference between the two groups was significant (RR 0.50; 95% confidence interval (CI) 0.34-0.72). Similarly, seven studies that compared ondansetron and a placebo identified a relatively lower incidence of PONV in the ondansetron group (103/277, 37.2%) than in the placebo group (177/270, 65.6%). The difference between the two groups was also significant (RR 0.58; 95% CI 0.43-0.79). The combination of dexamethasone and ondansetron was significantly more effective at reducing the incidence of POV than dexamethasone or ondansetron alone. In all included RCTs, experimental drug-related complications, such as facial flushing and headache, were limited. CONCLUSIONS: Surgeons and anesthesiologists are recommended to administer the combination of dexamethasone and ondansetron to pediatric patients undergoing strabismus surgery.

Extended silicone oil tamponade in primary vitrectomy for complex retinal detachment in proliferative diabetic retinopathy: a long-term follow-up study.

PURPOSE: To investigate long-term anatomic and functional results of extended silicone oil (SO) tamponade in primary vitrectomy for patients with proliferative diabetic retinopathy (PDR) and complex retinal detachment (RD). METHODS: From January 1999 to June 2005, clinical records of consecutive patients with PDR who underwent primary vitrectomy with extended SO tamponade for complex RD were retrospectively reviewed. Main outcome measures included anatomic outcome, functional outcome, and postoperative complications. Statistical analyses were used to determine factors affecting anatomic and functional outcomes and to evaluate the potential adverse effects on vision from long-term oil tamponade. RESULTS: Fifty-four eyes of 45 patients (18 male and 27 female) were included in this series. All patients underwent follow-up >or= 12 months (28.2+/-15.1 months; range: 12 to 69 months). Anatomic success was achieved in 85.2% at the third month postoperatively and 83.3% at last followup. Breaks with adjacent unreleased traction was identified as the only variable associated with final anatomic success (OR=0.173, p=0.024). Best-corrected visual acuity (BCVA) improved or remained unchanged in 89% at the third month postoperatively and in 78% at last follow-up. Ambulatory vision was achieved in 41% at the third month postoperative and 44% at last follow-up. Preoperative BCVA was identified as the only variable statistically associated with final BCVA (p<0.001) (multivariate analysis). The change of BCVA from the third month to last follow-up has no correlation with follow-up duration in the 45 eyes with final anatomic success (Pearson correlation coefficient = -0.022, p=0.888). Postoperative complications included peri-silicone oil proliferation in 4 eyes, neovascular glaucoma in 4 eyes, oil migration into anterior chamber in 9 eyes, and pupillary-block induced IOP elevation in 5 eyes. CONCLUSIONS: Prolonged SO tamponade may provide anatomic success and functional stability after primary diabetic vitrectomy. Significant complications compromising visual prognosis were uncommon with prolonged SO tamponade.

Full-thickness central corneal grafts in lamellar keratoscleroplasty to treat limbal dermoids.

PURPOSE: To assess the surgical outcomes in patients who underwent lamellar keratoscleroplasty with full-thickness central corneal grafts for limbal dermoids. DESIGN: Retrospective, noncomparative, analysis of a consecutive case series with chart review. PARTICIPANTS: Ten patients (6 male, 4 female; mean age, 12.3+/-5.0 years; range, 5.7-22.4 years) with 10 limbal dermoids in 10 eyes undergoing lamellar keratoscleroplasty with full-thickness central corneal grafts between 1992 and 2003 at National Taiwan University Hospital were studied. METHODS: The medical records and external eye photographs were reviewed. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), corneal astigmatism and topography, cosmetic outcomes, and surgical complications were measured as outcome indicators. For analysis of the surgical effect on corneal astigmatism, the 9 patients with topographic data available were divided into 2 groups according to their preoperative corneal astigmatism (group 1, > or =6 diopters [D]; group 2, <6 D). RESULTS: The mean earliest recorded BCVA and the latest postoperative BCVA were 6/30 and 6/10, respectively, and the improvement of BCVA after operation combined with amblyopia treatment was 4.9+/-3.6 lines on a Snellen chart. Patients with preoperative astigmatism > or =6.0 D (9.7+/-1.0 D; n = 4) were found to have a marked decrease in astigmatism after surgery (astigmatism change, 5.2+/-1.7 D). Patients with preoperative astigmatism <6.0 D (3.4+/-0.2 D; n = 5) were found to have an insignificant increase in astigmatism after surgery (astigmatism change, 0.0+/-0.6 D). After surgery, significant corneal opacity was found in 1 patient; mild bluish scleral hue was found in 3 patients. Surgical complications included prolonged reepithelialization, interface neovascularization, graft rejection, and steroid glaucoma. CONCLUSIONS: Using full-thickness central corneal grafts in lamellar keratoscleroplasty for limbal dermoids achieved good cosmetic results with limited postoperative complications. Operation may markedly reduce corneal astigmatism in patients with high preoperative corneal astigmatism. Visual prognosis is good in patients undergoing surgery combined with adequate amblyopia treatment.