Biometric refractive error after cataract and retina surgery: a systematic review and a benchmark proposal.

PURPOSE: To systematically review studies on refractive error after phacovitrectomy and phacoemulsification and to investigate factors associated with larger error. MATERIALS AND METHODS: A literature search was performed using PUBMED and EMBASE until May 2020. The articles were included in the study if they reported data about refractive error as the difference in spherical equivalent between actual vs. target refraction in patients who underwent phacovitrectomy and phacoemulsification according to the type of biometry (ultrasound or optical). An inverse variance meta-analysis technique was used to pool errors; standard deviations (SDs), which are an expression of random error, were reported descriptively as median and range of the 95% coefficient of reproducibility (95% CR: 1.96 SD). RESULTS: Twenty-one studies (197,353 eyes) were included. The mean error obtained using optical biometry was negligible for phacoemulsification (0.04 D, 95% CI: -0.04 to 0.12; 8 studies, 587 eyes) and was consistent with larger datasets using mixed biometric methods (0.02, 95% CI -0.07 to 0.04; 5 studies, 194,522 eyes). A trend towards hyperopia was found with ultrasound biometry after phacoemulsification (+0.21 D, 0.00-0.42 D; 7 studies, 394 eyes). Mean error after phacovitrectomy was clinically insignificant with optical biometry (-0.10 D, -0.22 to 0.02;, 8 studies, 453 eyes), and) and a mild myopic shift was possible with ultrasound biometry (-0.39 D, 95% CI: -0.68 to -0.09 D; 6 studies, 529 eyes). The 95% CR was greater and more variable with ultrasound biometry in patients who underwent phacovitrectomy (median 1.75 D, range 0.47-2.5) while it was consistent and lower with optical biometry in patients who underwent phacoemulsification (median 0.96 D, range 0.60-1.2]). CONCLUSIONS: Phacovitrectomy causes a mild myopic shift compared to phacoemulsification, which is clinically relevant only with ultrasound biometry. Furthermore, our review provides estimates of fixed and random error for postoperative vs. target spherical equivalent as a continuous variable, that is easy to use as benchmark for quality assurance.

Accuracy of optical coherence tomography for diagnosing glaucoma: an overview of systematic reviews.

AIMS: To assess the diagnostic accuracy (DTA) of optical coherence tomography (OCT) for detecting glaucoma by systematically searching and appraising systematic reviews (SRs) on this issue. METHODS: We searched a database of SRs in eyes and vision maintained by the Cochrane Eyes and Vision United States on the DTA of OCT for detecting glaucoma. Two authors working independently screened the records, abstracted data and assessed the risk of bias using the Risk of Bias in Systematic Reviews checklist. We extracted quantitative DTA estimates as well as qualitative statements on their relevance to practice. RESULTS: We included four SRs published between 2015 and 2018. These SRs included between 17 and 113 studies on OCT for glaucoma diagnosis. Two reviews were at low risk of bias and the other two had two to four domains at high or unclear risk of bias with concerns on applicability. The two reliable SRs reported the accuracy of average retinal nerve fibre layer (RNFL) thickness and found a sensitivity of 0.69 (0.63 to 0.73) and 0.78 (0.74 to 0.83) and a specificity of 0.94 (0.93 to 0.95) and 0.93 (0.92 to 0.95) in 57 and 50 studies, respectively. Only one review included a clear specification of the clinical pathway. Both reviews highlighted the limitations of primary DTA studies on this topic. CONCLUSIONS: The quality of published DTA reviews on OCT for diagnosing glaucoma was mixed. Two reliable SRs found moderate sensitivity at high specificity for average RNFL thickness in diagnosing manifest glaucoma. Our overview suggests that the methodological quality of both primary and secondary DTA research on glaucoma is in need of improvement.

Antibiotic prophylaxis for preventing endophthalmitis after intravitreal injection: a systematic review.

PURPOSE: To assess the effect of topical antibiotic prophylaxis on the rate of post-operative endophthalmitis after intravitreal injection (IVI). METHODS: We conducted a systematic review of studies comparing the rates of endophthalmitis in eyes receiving IVI of different drugs with and without topical antibiotic prophylaxis, by searching MEDLINE and EMBASE up to June 2016. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool and the Risk Of Bias in Non-randomized Studies of Interventions (ROBINS-I) for randomized clinical trials (RCTs) and non-randomized studies, respectively. We used a random-effects meta-analysis to compute the odds ratio (OR) of endophthalmitis with antibiotic prophylaxis compared with no prophylaxis and conducted subgroup analyses to compare the efficacy of different regimens and classes of antibiotics on endophthalmitis rates. RESULTS: We identified 1 randomized and 12 non-randomized studies that reported 74 cases of endophthalmitis in 147,203 IVIs using antibiotic prophylaxis compared with 55 cases in 211,418 IVIs with no prophylaxis. The overall OR of endophthalmitis for antibiotic prophylaxis vs. no prophylaxis was 1.33 (95% CI 0.75-2.38). Leave-one-out sensitivity analyses showed that the exclusion of the only study with a serious risk of bias significantly increased the risk of endophthalmitis in the antibiotic prophylaxis group compared with control (OR: 1.62, 95% CI: 1.17, 2.34). There was no difference in the endophthalmitis rate associated with any other factor analyzed, including type of antibiotic, type of drug injected, or antibiotic prophylaxis regimen. CONCLUSIONS: Antibiotic prophylaxis does not reduce the rate of endophthalmitis following IVI and might potentially be associated with an increased risk of post-operative infection.

OCULAR HYPERTENSION AND GLAUCOMA FOLLOWING VITRECTOMY: A Systematic Review.

PURPOSE: Pars plana vitrectomy has been reported to increase the risk of ocular hypertension and open-angle glaucoma. The authors conducted a systematic review of randomized and nonrandomized studies to compare the incidence of open-angle glaucoma and ocular hypertension in vitrectomized versus nonvitrectomized eyes. METHODS: A literature search was performed using MEDLINE and EMBASE until August 2016. Data on ocular hypertension and open-angle glaucoma incidence and mean intraocular pressure after at least 1 year were pooled using random-effects metaanalysis models. Because only nonrandomized studies were retrieved, ROBINS-I tool was used to assess risk of bias in the review. RESULTS: Seven included studies had a paired design to compare the outcomes of vitrectomized versus fellow eyes, with mean follow-up of least 12 months. Four studies (851 patients) provided data on open-angle glaucoma: incidence in vitrectomized versus non-vitrectomized eyes was 7.8% and 4.8%, respectively, yielding a metaanalytic odds ratio of 1.67 (95% CI: 1.08-2.57). Six studies (1,060 patients) reported on the occurrence of ocular hypertension, which was 5.8% in vitrectomized eyes versus 3.1% in fellow eyes (odds ratio: 2.03, 95% CI: 0.97-4.22), without significant differences in the mean postoperative intraocular pressure (mean difference 0.31 mmHg, 95% CI: -0.26 to 0.89). CONCLUSION: Although the review found increased risk of open-angle glaucoma with pars plana vitrectomy, the studies were heterogenous or inconsistent regarding ocular hypertension and intraocular pressure increase. Larger studies should be conducted in homogenous cohorts of patients undergoing macular surgery, excluding complex conditions such as retinal detachment or diabetic retinopathy.

Diagnostic accuracy research in glaucoma is still incompletely reported: An application of Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015.

BACKGROUND: Research has shown a modest adherence of diagnostic test accuracy (DTA) studies in glaucoma to the Standards for Reporting of Diagnostic Accuracy Studies (STARD). We have applied the updated 30-item STARD 2015 checklist to a set of studies included in a Cochrane DTA systematic review of imaging tools for diagnosing manifest glaucoma. METHODS: Three pairs of reviewers, including one senior reviewer who assessed all studies, independently checked the adherence of each study to STARD 2015. Adherence was analyzed on an individual-item basis. Logistic regression was used to evaluate the effect of publication year and impact factor on adherence. RESULTS: We included 106 DTA studies, published between 2003-2014 in journals with a median impact factor of 2.6. Overall adherence was 54.1% for 3,286 individual rating across 31 items, with a mean of 16.8 (SD: 3.1; range 8-23) items per study. Large variability in adherence to reporting standards was detected across individual STARD 2015 items, ranging from 0 to 100%. Nine items (1: identification as diagnostic accuracy study in title/abstract; 6: eligibility criteria; 10: index test (a) and reference standard (b) definition; 12: cut-off definitions for index test (a) and reference standard (b); 14: estimation of diagnostic accuracy measures; 21a: severity spectrum of diseased; 23: cross-tabulation of the index and reference standard results) were adequately reported in more than 90% of the studies. Conversely, 10 items (3: scientific and clinical background of the index test; 11: rationale for the reference standard; 13b: blinding of index test results; 17: analyses of variability; 18; sample size calculation; 19: study flow diagram; 20: baseline characteristics of participants; 28: registration number and registry; 29: availability of study protocol; 30: sources of funding) were adequately reported in less than 30% of the studies. Only four items showed a statistically significant improvement over time: missing data (16), baseline characteristics of participants (20), estimates of diagnostic accuracy (24) and sources of funding (30). CONCLUSIONS: Adherence to STARD 2015 among DTA studies in glaucoma research is incomplete, and only modestly increasing over time.

STARD 2015 was reproducible in a large set of studies on glaucoma.

AIM: To investigate the reproducibility of the updated Standards for the Reporting of Diagnostic Accuracy Studies tool (STARD 2015) in a set of 106 studies included in a Cochrane diagnostic test accuracy (DTA) systematic review of imaging tests for diagnosing manifest glaucoma. METHODS: One senior rater with DTA methodological and clinical expertise used STARD 2015 on all studies, and each of three raters with different training profiles assessed about a third of the studies. RESULTS: Raw agreement was very good or almost perfect between the senior rater and an ophthalmology resident with DTA methods training, acceptable with a clinical rater with little DTA methods training, and only moderate with a pharmacology researcher with general, but not DTA, systematic review training and no clinical expertise. The relationship between adherence with STARD 2015 and methodological quality with QUADAS 2 was only partial and difficult to investigate, suggesting that raters used substantial context knowledge in risk of bias assessment. CONCLUSIONS: STARD 2015 proved to be reproducible in this specific research field, provided that both clinical and DTA methodological expertise are achieved through training of its users.

Dietary profile of patients with Stargardt's disease and Retinitis Pigmentosa: is there a role for a nutritional approach?

BACKGROUND: Stargardt's disease (STGD) and Retinitis Pigmentosa (RP) are inherited retinal degenerations that may be affected, in opposite way, by diet. METHODS: Dietary profile was assessed in 24 patients with STGD and in 56 patients with RP. We documented in only 6 out of 24 (25%) STGD patients a daily intake of vitamin A within the recommended range while 14/24 (58.3%) reported a high daily intake and 4/24 (16.7%) showed a low daily intake. With regard to RP, 4/56 (7.1%) reported to be within the recommended range, 37/56 (66.1%) reported high daily intake and 15/56 (26.8%) showed low daily intake of vitamin A. RESULTS: Interestingly, STGD patients with low vitamin A intake (<600 µg RAE/day) showed significantly better visual acuity with respect to those introducing higher intake of vitamin A. CONCLUSION: The present study suggests insuitable nutrient intakes among patients with STGD and RP, especially for daily intake of vitamin A. The results may be used to provide tailored nutritional interventions in these patients.

Computer assisted evaluation of retinal vessels tortuosity in Fabry disease.

PURPOSE: Fabry Disease (FD) is a rare X-linked metabolic disorder characterized by diffuse deposition of sphingolipids in many tissues. Retinal vessel tortuosity is a common ocular manifestation in FD and may represent a useful marker for the disease. Unfortunately its clinical evaluation is poorly reproducibile and alternative means of evaluation may be of interest. We tested a new semi-automatic software measuring retinal vessel tortuosity from eye fundus digital images in a group of FD patients. METHODS: Observational case-control study evaluating four mathematical parameters describing tortuosity (relative length, sum of angle metric [SOAM], product of angle distance [PAD], triangular index) obtained from fundus pictures of 35 FD patients and 35 age-matched controls. Only the right eye was considered in order to reduce bias. Mann-Whitney test was used to compare the FD group versus the control group, males versus females and patients with versus without clinically identified retinal vessels tortuosity in the FD group. Linear regression analysis was performed on a subgroup of patients to evaluate the possible association of retinal vessels tortuosity parameters with age and with markers of systemic disease's progression. RESULTS: Three parameters (SOAM, PAD and triangular index) were significantly higher in FD patients in comparison with the controls (p < 0.0001, p = 0.001, p = 0.002 respectively). In the FD group the same three parameters showed higher values in hemizygous males than in heterozygous females ((p < 0.0001, p = 0.002, p < 0.0001 respectively). CONCLUSION: A computer assisted analysis of retinal vasculature demonstrated an increased vessels tortuosity in FD patients. The technique might be useful to establish disease severity and monitor its progression.

Treatment of macular serous neuroretinal detachment in tilted disk syndrome: report of 3 cases.

PURPOSE: To describe functional and anatomic results obtained by treatment with photodynamic therapy (PDT) or intravitreal bevacizumab (Avastin, Roche) in macular serous retinal detachment associated with tilted disk syndrome. METHODS: Three eyes of 3 patients with symptomatic macular serous detachment associated with tilted disc syndrome (optic disc with an oblique axis, inferonasal crescent, and inferior staphyloma) were treated. In all patients, best-corrected visual acuity (BCVA) was tested and fluorescein angiography (FA) and optical coherence tomography (OCT) were performed before and about 45 days after treatment. All patients underwent a complete ophthalmologic examination including OCT at least 6 months after treatment. The first patient was treated with one low fluence (300 mW/cm2 for 83 seconds) PDT (6 months follow-up). The second patient was treated with 3 intravitreal injections of bevacizumab 1.25 mg (33 months follow-up) and the third patient was treated with 2 low fluence PDTs at 4 months and, after 1 year, 3 intravitreal injections of bevacizumab 1.25 mg (37 months follow-up). RESULTS: Before treatment, all patients complained of visual loss and metamorphopsia. The OCT showed in the macular area a focal neurosensory detachment with foveal involvement. The FA showed in the macular area multiple focal areas of hyperfluorescence due to pigment epithelium atrophy and in the second and third patient also a hyperfluorescent pinpoint with minimal leakage. After treatment in all eyes, symptoms did not change, BCVA remained stable, and in OCT the foveal neuroretinal detachment was changeless. In FA, no noticeable variation of the hyperfluorescence areas was appreciated. In the second patient, the hyperfluorescent point remained unvaried, and the same occurred in the third patient after the first PDT, while after the second PDT a new leaking dot disappeared. CONCLUSIONS: Macular serous retinal detachment was first described in 1998 as an uncommon complication of tilted disc syndrome showing angiographic and OCT features similar to a chronic central serous chorioretinopathy. In contrast to this pathology, in our patients treatment with PDT or intravitreal bevacizumab did not succeed, probably because of a different pathogenesis of macular serous detachment. Further investigations are needed to clarify the proper therapy of this disease.