Effectiveness of Microcurrent Stimulation in Preserving Retinal Function of Blind Leading Retinal Degeneration and Optic Neuropathy: A Systematic Review.

OBJECTIVES: To systematically identify and summarize the effectiveness and the parameters of electrical stimulation (ES) for the preservation of visual function in major retinal degeneration and optic neuropathy. MATERIALS AND METHODS: A systematic review of clinical studies, using ES therapy in patients with blind leading retinal degenerations, including retinitis pigmentosa (RP), age-related macular degeneration (AMD), glaucoma, retinal vein occlusion (RVO), retinal artery occlusion (RAO), and optic neuropathy was conducted. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for relevant interventional studies including randomized controlled trials (RCTs) and observational studies. RESULTS: A total of 10 RCTs and 15 observational studies were included. Transcorneal ES (TcES), transpalpebral ES (TpES), transdermal ES (TdES), and repetitive transorbital alternating current stimulation (rtACS) were used for the treatment of the patients. ES using 20 Hz biphasic pulses with current strength at 150%-200% of individual electrical phosphene threshold (EPT) for RP patients showed improved retinal function detected by visual acuity (VA), visual field (VF), or electrical retinal graphs (ERG). rtACS on patients with optic neuropathy showed significant preservation of VA and VF. Clinical studies on AMD, RAO, and glaucoma indicated promising protective effects of ES on the visual function, though the amount of evidence is limited. CONCLUSIONS: ES treatment has promising therapeutic effects on RP and optic neuropathy. More large-scale RCT studies should be conducted to elucidate the potential of ES, especially on AMD, RAO, and glaucoma. A comparison of the effects by different ES methods in the same disease populations is still lacking. Parameters of the electric current and sensitive detection method should be optimized for the evaluation of ES treatment effects in future studies.

Prospective study on a novel treatment for leaking cystic bleb: Efficacy and safety of collagen crosslinking.

IMPORTANCE: Management of cystic bleb leak is difficult. It would be essential to look for a method to strengthen the original pathological conjunctiva and reverse bleb leak. BACKGROUND: To evaluate the long-term efficacy and safety of collagen crosslinking in patients with leaking cystic bleb. DESIGN: Prospective interventional case series at a university-based hospital. PARTICIPANTS: Twelve eyes in 12 subjects with late-onset bleb leak from cystic bleb, without indications for prompt surgical interventions were included. METHODS: The subjects underwent crosslinking with 0.1% riboflavin application to bleb surface, followed by ultraviolet irradiation for 30 minutes. The subjects were followed up at baseline and at 1 week, 1 month, 3 months, 6 months post-treatment and then every 6 months afterwards. MAIN OUTCOME MEASURES: Interval from treatment to cessation of bleb leak, recurrence rate of bleb leak and side effects of treatment. RESULTS: The mean follow-up after crosslinking was 29.33 ± 12.45 months. Bleb leak subsided in 11 (92%) of 12 patients after a single session of crosslinking, after 1 to 8 weeks (median 3 weeks). Time to leak cessation was significantly correlated with the number of prior glaucoma interventions (R = .71, P = .014). Bleb wall at 3 months was significantly thicker than at baseline (0.70 ± 0.67 vs 0.81 ± 0.62 mm, P = .008). None of the patients experienced any complications. CONCLUSIONS AND RELEVANCE: Crosslinking achieves resolution of cystic bleb leak which lasts for at least 12 months, without the need of subsequent surgical interventions. Crosslinking is a simple, non-invasive treatment for bleb leak. It aims to restore the integrity of conjunctiva.

Systematic Review on Therapeutic Strategies to Minimize Corneal Stromal Scarring After Injury.

OBJECTIVES: To evaluate recent studies on available and experimental therapies in preventing or minimizing corneal stromal scarring after injury. METHODS: We performed an Entrez PubMed literature search using keywords "cornea," "scarring," "haze," "opacity," "ulcer," "treatments," "therapies," "treatment complications," and "pathophysiology" resulting in 390 articles of which 12 were analyzed after filtering, based on English language and publication within 8 years, and curation for relevance by the authors. RESULTS: The 12 articles selected included four randomized control trials (RCTs) (two were double-blinded placebo-controlled RCTs, one was a prospective partially masked RCT, and one was an open-label RCT), two retrospective observational studies, and six laboratory-based studies including two studies having in vivo and in vitro experiments, one was in vivo study, one was ex vivo study, and the last two were in vitro studies. The current mainstay for preventing or minimizing corneal scarring involves the use of topical corticosteroids and local application of mitomycin C. However, supportive evidence for their use in clinical practice from well-designed RCTs is lacking. Laboratory studies on topical rosiglitazone therapy, vitamin C prophylaxis, gene therapy, and stem cell therapy have shown promising results but have yet to be translated to clinical research. CONCLUSION: There is a need for more robust randomized controlled trials to support treatments using topical corticosteroids and mitomycin C. Furthermore, their clinical efficacy and safety profile should be compared with new treatments that have shown promising results in the laboratory setting. Ultimately, the goal should be to personalize cornea scarring treatment according to the most effective treatment for the specific underlying pathology.

Early epithelial complications of accelerated trans-epithelial corneal crosslinking in treatment of keratoconus: a case series.

BACKGROUND: To report a case series of early postoperative complications following combined accelerated corneal crosslinking (CXL) and trans-epithelial technique in keratoconus. CASE PRESENTATIONS: Eleven eyes underwent accelerated trans-epithelial CXL (18 mW/cm2 for 5 min). Seven eyes (64%) developed complications in the first week postoperatively. Five eyes had large epithelial defects, and two eyes were complicated with diffuse punctate epithelial erosions. Early transient stromal haze was seen in eyes with epithelial complications. Anterior segment optical coherence tomography showed a faint demarcation line in six eyes (55%) with epithelial complications. CONCLUSION: A significant number of eyes developed epithelial complications shortly after combined accelerated trans-epithelial CXL, which defeated the benefits of leaving the epithelium intact.

A cross-sectional comparative study on chronic ocular manifestations of Stevens-Johnson syndrome and toxic epidermal necrolysis in Chinese eyes: a 15-year case series.

PURPOSE: To compare the chronic ocular manifestations in Stevens-Johnson syndrome and toxic epidermal necrolysis patients from a 15-year cohort. METHODS: All SJS and TEN patients admitted to our burn intensive care unit between 1999 and 2014 were invited for assessment. Slit-lamp examination was performed, and ocular condition was graded according to the Sotozono scoring System, which depended on the extent of cornea, conjunctiva and lid involvement. Tear osmolarity was also measured. RESULTS: A total of 18 SJS and 4 TEN cases with an average of 92 and 135 months from disease onset were included. The average age of onset was 46.4 ± 16.6 in SJS and 43.5 ± 19.3 in TEN patients. The LogMAR visual acuity was 0.209 ± 0.591 in SJS and 0.489 ± 0.688 in TEN patients (p = 0.048). The average total Sotozono score was 3.75 ± 7.32 in SJS and 6.88 ± 9.49 in TEN (p = 0.358). Neither the age of onset (p = 0.787), length of follow-up (p = 0.256) nor disease type (SJS vs TEN, p = 0.188) predicted the Sotozono score. There was a statistically significant correlation between Sotozono score and LogMAR VA (r s = 0.437, p = 0.003). CONCLUSION: The average total Sotozono score was higher in the TEN group than in the SJS group, but the difference was not statistically significant. Nevertheless, the score correlated with the visual acuity which was statistically worse in the TEN group.

Comparison of the acute ocular manifestations of Stevens-Johnson syndrome and toxic epidermal necrolysis in Chinese eyes: a 15-year retrospective study.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening conditions that initially affect the skin and mucous membranes. The aim of this study was to compare the acute ocular manifestations between SJS and TEN. METHODS: The initial presenting ophthalmic records of patients with either SJS (<30% body surface area involvement) or TEN (> = 30% involvement), who were treated at one tertiary burn center in Hong Kong between 1999 and 2014, were retrospectively analyzed and compared. RESULTS: A total of 20 SJS and 12 TEN cases were included. All were drug-induced. The patient demographics and treatment received were comparable. Overall, 40% of SJS and 75% of TEN patients had acute ocular surface inflammation. When comparing the two groups, there was a significant difference in the number of cases with mild involvement (5% in SJS, 42% in TEN, p = 0.01), while no statistically significant differences were found (p > 0.05) comparing between the moderate (15% in SJS, 0% in TEN) and severe groups (20% in SJS, 33% in TEN). CONCLUSIONS: Ocular surface inflammation was common during the acute phase in both SJS and TEN. TEN had a significantly higher number of cases with mild ocular involvement when compared with SJS, but no significant difference between the number of moderate and severe cases between the two groups.

A review of selective laser trabeculoplasty in the Hong Kong Chinese population.

INTRODUCTION: Selective laser trabeculoplasty was first introduced to Hong Kong in 2004 for intra-ocular pressure lowering in the treatment of primary glaucoma. Since then, it has gained popularity as an alternative to anti-glaucoma medications and as a bridging therapy prior to more invasive glaucoma surgeries because of the high safety profile of the laser. METHODS: An Ovid search was performed using "selective laser trabeculoplasty" as the key word, which identified 190 unique articles; 24 reviews and/or meta-analyses were excluded. All remaining abstracts of original articles were in English. This review particularly focuses on the local population by summarising the findings from peer-reviewed publications that involved a Hong Kong Chinese population. RESULTS AND CONCLUSION: This review addresses some of the clinically relevant questions relating to selective laser trabeculoplasty including laser application, optimal energy, efficacies and success rates among different glaucoma subtypes, predictors of success, adverse effects, and intra-ocular pressure fluctuation after selective laser trabeculoplasty.

Involutional entropion: risk factors and surgical remedies.

PURPOSE OF REVIEW: To review current surgical practices for the repair of lower eyelid involutional entropion with a focus on recent studies. RECENT FINDINGS: A shorter axial length, which may be interrelated with exophthalmometry, correlates with involutional entropion. Although it is known Asian eyelids more frequently develop involutional entropion, there is greater awareness of customized surgical approaches. Minimally invasive techniques for strengthening the action of lower eyelid retractors, such as everting sutures and transconjunctival approaches, continue to be refined and studied. Such surgery is efficacious in patients who do not have horizontal laxity. However, there is consistent evidence that in the presence of laxity the recurrence rate is higher if the eyelid is not horizontally tightened. SUMMARY: By knowing of the demographics and factors associated with involutional entropion, clinicians can have better understanding of the condition and the patients most at risk. There is not sufficient evidence to determine whether a short axial length is an independent-risk factor for entropion. Advances in surgical technique have led to continued interest in minimally invasive approaches. Precision in addressing individual patients' underlying anatomic abnormalities is important.

Differences in corneal parameters between normal tension glaucoma and primary open-angle glaucoma.

The purpose of this study was to identify the differences in corneal parameters between medically treated normal tension glaucoma (NTG) and primary open-angle glaucoma (POAG) subjects. This cross-sectional study from September 2011 to September 2012 included consecutive subjects with POAG and NTG who were receiving topical anti-glaucoma medications at the time of the study. Subjects were excluded if they had pre-existing corneal pathology or scars and previous glaucoma lasers. The following parameters were compared between the NTG and POAG groups: endothelial cell count, central corneal thickness (CCT), spherical equivalent, presenting and current intraocular pressure (IOP), number and type of anti-glaucoma medication, retinal nerve fibre layer thickness, visual field index, visual acuity, and phakic status. Only the right eye was used for statistical analysis. The right eye of the 30 NTG and 28 POAG subjects had comparable baseline characteristics, post-treatment IOP, and glaucoma severity. The endothelial cell count was significantly lower in the NTG versus the POAG group (2,380.0 ± 315.4 vs. 2,530.0 ± 320.4 cells/mm(2), p = 0.04). There were no significant differences in the spherical equivalent or CCT between the NTG and POAG groups. A significantly lower corneal endothelial cell count was found in NTG compared to POAG.

The association between clinical parameters and glaucoma-specific quality of life in Chinese primary open-angle glaucoma patients.

OBJECTIVE. To investigate the association between clinical measurements and glaucoma-specific quality of life in Chinese glaucoma patients. DESIGN. Cross-sectional study. SETTING. An academic hospital in Hong Kong. PATIENTS. A Chinese translation of the Glaucoma Quality of Life-15 questionnaire was completed by 51 consecutive patients with bilateral primary open-angle glaucoma. The binocular means of several clinical measurements were correlated with Glaucoma Quality of Life-15 findings using Pearson's correlation coefficient and linear regression. The measurements were the visual field index and pattern standard deviation from the Humphrey Field Analyzer, Snellen best-corrected visual acuity, presenting intra-ocular pressure, current intra-ocular pressure, average retinal nerve fibre layer thickness via optical coherence tomography, and the number of topical anti-glaucoma medications being used. RESULTS. In these patients, there was a significant correlation and linear relationship between a poorer Glaucoma Quality of Life-15 score and a lower visual field index (r=0.3, r(2)=0.1, P=0.01) and visual acuity (r=0.3, r(2)=0.1, P=0.03). A thinner retinal nerve fibre layer also correlated with a poorer Glaucoma Quality of Life-15 score, but did not attain statistical significance (r=0.3, P=0.07). There were no statistically significant correlations for the other clinical parameters with the Glaucoma Quality of Life-15 scores (all P values being >0.7). The three most problematic activities affecting quality of life were "adjusting to bright lights", "going from a light to a dark room or vice versa", and "seeing at night". CONCLUSION. For Chinese primary open-angle glaucoma patients, binocular visual field index and visual acuity correlated linearly with glaucoma-specific quality of life, and activities involving dark adaptation were the most problematic.

Primary acute angle closure: long-term clinical outcomes over a 10-year period in the Chinese population.

To investigate long-term clinical outcomes after acute angle closure in the Chinese population. A 10-year retrospective review of primary acute angle closure in Hong Kong Chinese to document patient demographics, treatment, and pre- and post-acute angle closure intraocular pressure (IOP) and visual acuity (VA). The year of attack was correlated with the timing of laser, last VA and IOP, and the number of anti-glaucoma eye drops. In 210 eyes (200 patients), 10 % had a simultaneous bilateral acute angle closure. VA improvement was noted in 68.6 % of eyes whilst 11.4 % were blinded. At 3.7 ± 2.4 years of follow-up, 49.5 % had IOP <21 mmHg with medication or surgery, 41.9 % needed anti-glaucoma eye drops, and 13.8 % had undergone trabeculectomy. The older the year of attack, the poorer the VA (r = 0.2, p = 0.03) and the longer the laser wait time (r = 0.3, p < 0.0001). VA outcome and laser promptness in acute angle closure has improved over the years. At 4 years after the attack, 50 % had normal IOP, 69 % had improved VA but 11 % were blinded.

Sector-Based Regression Strategies to Reduce Refractive Error-Associated Glaucoma Diagnostic Bias When Using OCT and OCT Angiography.

Purpose: This cross-sectional study aimed to investigate the sectoral variance of optical coherence tomography (OCT) and OCT angiography (OCTA) glaucoma diagnostic parameters across eyes with varying degrees of refractive error. Methods: Healthy participants, including individuals with axial ametropia, enrolled in the Hong Kong FAMILY cohort were imaged using the Avanti/AngioVue OCT/OCTA system. The OCT and OCTA parameters obtained include peripapillary nerve fiber layer thickness (NFLT), peripapillary nerve fiber layer plexus capillary density (NFLP-CD), and macular ganglion cell complex thickness (GCCT). Sectoral measurements of NFLT, NFLP-CD, and GCCT were based on sectors and hemispheres. Results: A total of 1339 eyes from 791 participants were stratified based on spherical equivalent refraction: high myopia (<-6 D), low myopia (-6 D to -1 D), emmetropia (-1 D to 1 D), and hyperopia (>1 D). Multivariable broken stick regression models, accounting for age, sex, and signal strength, showed that all NFLT sectors except temporally, the inferior GCCT hemisphere, and half of the NFLP-CD sectors were more affected by ametropia-related covariates than the corresponding global parameters. As expected, the false-positive rates in those sectors were elevated. Finally, sector-specific axial length (AL) and spherical equivalent (SE) adjustments helped reduce the elevated false-positive rates. Conclusions: The effect of optical magnification is even more prominent among sectors than the global parameters. AL- and SE-based adjustments should be individualized to each sector to mitigate this magnification bias effectively. Translational Relevance: Identifying sectoral differences among diagnostic parameters and adopting these sector-based adjustments into commercial OCT systems will hopefully reduce false-positive rates related to refractive error.

Medication-induced acute angle closure attack.

OBJECTIVE: To review acute angle closure attacks induced by local and systemic medications. DATA SOURCES: PubMed literature searches up to August 2011. STUDY SELECTION: The following key words were used for the search: "drug", "iatrogenic", "acute angle closure glaucoma". DATA EXTRACTION: A total of 86 articles were retrieved using the key words. Only those concerning acute angle closure attack triggered by local or systemic drug administration were included. For articles on the same or related topics, those published at later or more recent dates were selected. As a result, 44 articles were included and formed the basis of this review. DATA SYNTHESIS: An acute attack of angle closure can be triggered by dilatation of the pupil, by anatomical changes in the ciliary body and iris, or by movement of the iris-lens diaphragm. Local and systemic medications that cause these changes have the potential to precipitate an attack of acute angle closure. The risk is higher in subjects who are predisposed to the development of angle closure. Many pharmaceutical agents including ophthalmic eyedrops and systemic drugs prescribed by general practitioners and various specialists (in psychiatry, otorhinolaryngology, ophthalmology, medicine, and anaesthesia) can precipitate an acute angle closure attack. The medications include: anti-histamines, anti-epileptics, antiparkinsonian agents, antispasmolytic drugs, mydriatic agents, sympathetic agents, and botulinum toxin. CONCLUSION: Since acute angle closure attack is a potentially blinding eye disease, it is extremely important to be vigilant and aware of ophthalmic and systemic medications that can lead to such attacks in predisposed subjects and to diagnose the condition when it occurs.

Prospective study on retinal nerve fibre layer changes after an acute episode of phacomorphic angle closure.

To investigate the retinal nerve fibre layer (RNFL) changes after an acute attack of phacomorphic angle closure. This prospective study involved ten cases of phacomorphic angle closure that underwent cataract extraction and intraocular lens insertion after intraocular pressure lowering. Apart from visual acuity and intraocular pressure (IOP), RNFL thickness and vertical cup disc ratio (VCDR) were measured by optical coherence tomography (OCT) at 3-9 months post attack. Humphrey visual field assessment was performed at 9 months post attack. All cases had mean phacomorphic duration of <5 days. Postoperatively, best correct Snellen visual acuity was 0.4 ± 0.2 and IOP at 9 months was 11.0 ± 3.1 mmHg. There was no difference in VCDR and RNFL between the attack and contralateral eye at 3 months post attack (both p = 0.4). At 9 months post attack, there was significant thinning in the average (p = 0.01), superior (p = 0.01), and inferior (p = 0.006) RNFL. There was no significant difference in the pattern standard deviation (PSD) between the two eyes on the Humphrey visual field nor was there any correlation between PSD severity and RNFL thinning (all p > 0.2. Patients with <5 days duration of phacomorphic angle closure are likely to have reasonable postoperative vision. An acute episode of phacomorphic angle closure can trigger an accelerated RNFL thinning despite normal IOP and open angles, most noticeable in the superior and inferior quadrants, occurring between 3 and 9 months post attack. Glaucomatous optic neuropathy in the attack eye was evident by OCT but not by visual field assessment at the same time interval.

Regression-Based Strategies to Reduce Refractive Error-Associated Glaucoma Diagnostic Bias When Using OCT and OCT Angiography.

Purpose: The purpose of this study was to correct refractive error-associated bias in optical coherence tomography (OCT) and OCT angiography (OCTA) glaucoma diagnostic parameters. Methods: OCT and OCTA imaging were obtained from participants in the Hong Kong FAMILY cohort. The Avanti/AngioVue OCT/OCTA system was used to measure the peripapillary nerve fiber layer thickness (NFLT), peripapillary nerve fiber layer plexus capillary density (NFLP-CD), macular ganglion cell complex thickness (GCCT), and macular superficial vascular complex vascular density (SVC-VD). Healthy eyes, including ones with axial ametropia, were enrolled for analysis. Results: A total of 1346 eyes from 792 participants were divided into 4 subgroups: high myopia (<-6D), low myopia (-6D to -1D), emmetropia (-1D to 1D), and hyperopia (>1D). After accounting for age, sex, and signal strength, multivariable regression showed strong dependence in most models for NFLT, GCCT, and NFLP-CD on axial eye length (AL), spherical equivalent (SE) refraction, and apparent optic disc diameter (DD). Optical analysis indicated that AL-related transverse optical magnification variations predominated over anatomic variations and were responsible for these trends. Compared to the emmetropic group, the false positive rates were significantly (Chi-square test P < 0.003) elevated in both myopia groups for NFLT, NFLP-CD, and GCCT. Regression-based adjustment of these diagnostic parameters with AL or SE significantly (McNemar test P < 0.03) reduced the elevated false positive rates. Conclusions: Myopic eyes are biased to have lower NFLT, GCCT, and NFLP-CD measurements. AL- and SE-based adjustments were effective in mitigating this bias. Translational Relevance: Adoption of these adjustments into commercial OCT systems may reduce false positive rates related to refractive error.

A Serial Cross-Sectional Analysis of the Prevalence, Risk Factors and Geographic Variations of Reduced Visual Acuity in Primary and Secondary Students from 2000 to 2017 in Hong Kong.

Background: We would like to investigate the prevalence trend, potential risk factors and geographic features of reduced visual acuity (VA) in primary and secondary schoolchildren of Hong Kong. Methods: This was a serial cross-sectional study using historical data of schoolchildren aged 6 to 15 years from the annual health checks conducted at Student Health Service Centers across Hong Kong, for the school years of 2000/2001 to 2016/2017. Results: The prevalence of reduced VA increased from 49.23% (95% CI, 48.99-49.47) in 2000/2001 to 54.34% (95% CI, 54.10-54.58) in 2011/2012 but decreased to 51.42% (95% CI, 51.17-51.66) in 2016/2017. Girls were less susceptible than boys at age 6-7 (and in grade primary 1-2), but more susceptible at older ages. The prevalence in junior grades increased while the risk effect of grade reduced over the past 17 years. Geographic variation on the risk for reduced VA existed and spatial autocorrelation was positive. The difference in prevalence of reduced VA between Hong Kong and mainland China has decreased in recent years. Cross-border students living in mainland China were associated with a lower risk for reduced VA. Conclusions: Further study was proposed to investigate the environmental association between students living in and outside Hong Kong with the prevalence of reduced VA. Multi-level research should also be conducted to investigate the influence of compositional and contextual factors on the prevalence of reduced VA.

Phacoemulsification Versus Phacotrabeculectomy in Primary Angle-closure Glaucoma With Cataract: Long-Term Clinical Outcomes.

PRECIS: Phacotrabeculectomy was more effective in reducing intraocular pressure (IOP) and glaucoma drugs than phacoemulsification alone in primary angle-closure glaucoma (PACG) eyes with cataract but was associated with more postoperative complications, up to 5 years after surgery. PURPOSE: The purpose of this study was to compare long-term clinical outcomes of phacoemulsification versus phacotrabeculectomy in PACG eyes with cataract. PATIENTS AND METHODS: The 2 initial prospective randomized controlled trials recruited PACG eyes with cataract using the same criteria and randomized these eyes to receiving either phacoemulsification or phacotrabeculectomy. Clinical data up to 5 years of follow-up were pooled for retrospective analysis. RESULTS: Clinical data of 35 patients in the phacoemulsification group and 44 patients in the phacotrabeculectomy group were analyzed. At 5 years after surgery, the mean IOP was decreased by 20.7% and 29.5% from before surgery to 5 years after phacoemulsification and phacotrabeculectomy, respectively (P<0.001 for both groups). Phacotrabeculectomy was significantly more effective than phacoemulsification in reducing IOP up to 5 years after surgery (P<0.001). At 5 years, the mean number of glaucoma drugs required±1 SD was 1.6±1.2 in the phacoemulsification group, and 0.7±1.0 in the phacotrabeculectomy group (P=0.004). Phacotrabeculectomy was associated with more postoperative complications than phacoemulsification up to 5 years (25 complications in the phacotrabeculectomy group versus 6 in the phacoemulsification group, P<0.001). CONCLUSIONS: Phacoemulsification alone reduces IOP and the need for glaucoma drugs in PACG eyes with cataracts for up to 5 years. Phacotrabeculectomy was more effective in reducing IOP and glaucoma drugs than phacoemulsification alone but was associated with more postoperative complications, up to 5 years after surgery.

Does the COVID-19 Pandemic Spell the End for the Direct Ophthalmoscope?

Despite advances in ophthalmic diagnostics, the direct ophthalmoscope remains a key clinical skill taught to medical students and is the tool of choice for retina examination among non-ophthalmic physicians. However, in recent years viable alternatives have become available. The coronavirus disease 2019 (COVID-19) pandemic has forced a major re-thinking in medical education worldwide. In this commentary, we examined the current merits and limitations of the direct ophthalmoscope in both the clinical sense and in the context of infection control. Furthermore, we compared the direct ophthalmoscope with alternatives, including commercially available portable non-mydriatic fundus cameras, that would allow a change in focus during ophthalmic teaching. We concluded that the latter will better prepare our medical students for the age of telemedicine and deep-learning systems. While the COVID-19 pandemic will not be the sole reason for the 'death' of the direct ophthalmoscope, the global situation will inevitably serve to expedite long overdue changes in our teaching of ophthalmic skills to non-ophthalmic physicians.

Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts.

OBJECTIVE: To compare phacoemulsification alone versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma (CACG) with coexisting cataract. DESIGN: Prospective randomized clinical trial. PARTICIPANTS: Fifty-one medically uncontrolled CACG eyes with coexisting cataract of 51 patients. INTERVENTION: Recruited patients were randomized into group 1 (phacoemulsification alone) or group 2 (combined phacotrabeculectomy with adjunctive mitomycin C). Postoperatively, patients were reviewed every 3 months for 2 years. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) and requirement for topical glaucoma drugs. RESULTS: Twenty-seven CACG eyes were randomized into group 1, and 24 CACG eyes were randomized into group 2. Combined phacotrabeculectomy resulted in lower mean postoperative IOP than phacoemulsification alone at 3 months (14.0 vs. 17.0 mmHg, P = 0.01), 15 months (13.2 vs. 15.4 mmHg, P = 0.02), and 18 months (13.6 vs. 15.9 mmHg, P = 0.01). Combined phacotrabeculectomy resulted in 1.25 fewer topical glaucoma drugs (P<0.001) in the 24-month postoperative period, compared with phacoemulsification alone. Combined surgery was associated with more postoperative complications (P<0.001) and more progression of optic neuropathy (P = 0.03), compared with phacoemulsification alone. CONCLUSIONS: Combined phacotrabeculectomy with adjunctive mitomycin C is more effective than phacoemulsification alone in controlling IOP in medically uncontrolled CACG eyes with coexisting cataract. Combined phacotrabeculectomy is associated with more postoperative complications.

Enophthalmos caused by an orbital venous malformation.

Orbital vascular malformations usually present with proptosis. We report a case where a patient with an orbital venous malformation presented with enophthalmos. Since many underlying orbital pathologies, including orbital metastases, can cause enophthalmos, it is important to investigate patients properly. Computed tomographic imaging of the orbit remains the most useful tool in the management of patients with enophthalmos.