Immediate sequential bilateral cataract surgery (ISBCS): A single-site experience of 41 patients during the COVID-19 pandemic.

Background: The practice of immediate sequential bilateral cataract surgery (ISBCS) was more widely adopted in the UK during the COVID-19 pandemic, in response to limited surgical capacity and the risk of nosocomial infection. This study reports on a single site experience of ISBCS in Northern Ireland. Methods: Data was collected prospectively between 17th November 2020 and 30th November 2021. The ISBCS surgical protocol, recommended by RCOphth and UKISCRS, was followed. Primary outcomes measures were: postoperative visual acuity (VA), refractive prediction accuracy, intraoperative and postoperative complications. Results: Of 41 patients scheduled, 39 patients completed ISBCS and two patients underwent unilateral surgery (n=80 eyes). Mean age at the time of surgery was 71.6 years (standard deviation (SD) ±11.8 years). Median preoperative VA was 0.8 logMAR (range: PL to 0.2 logMAR). Seventeen (20.9%) eyes were highly myopic and 9 (11.1%) eyes were highly hypermetropic. Median cumulative dissipated phacoemulsification energy was 15.7 sec (range: 1.8 sec to 83.4 sec). Median case time was 10.4 min (range: 4.3 min to 37.1 min).One eye (1.3%) developed iritis secondary to a retained tiny cortical fragment. Four eyes (5.0%, n=3 patients) developed cystoid macular oedema, with full resolution. On wide field imaging, an asymptomatic unilateral peripheral suprachoroidal haemorrhage was noted in two highly myopic patients (axial lengths of 27.01mm and 25.05mm respectively). The posterior pole was spared, and both resolved spontaneously without any visual impairment. Conclusions: In our initial experience, ISBCS was found to be a safe approach to cataract surgery. Our patient cohort included eyes with dense cataracts and high ametropia. Further studies are required to assess patient reported outcome measures and the possible economic benefits of ISBCS in our local population.

A comparison of transient elastography with acoustic radiation force impulse elastography for the assessment of liver health in patients with chronic hepatitis C: Baseline results from the TRACER study.

Background: Liver stiffness measurements can be used to assess liver fibrosis and can be acquired by transient elastography using FibroScan® and with Acoustic Radiation Force Impulse imaging. The study aimed to establish liver stiffness measurement scores using FibroScan® and Acoustic Radiation Force Impulse in a chronic hepatitis C cohort and to explore the correlation and agreement between the scores and the factors influencing agreement. Methods: Patients had liver stiffness measurements acquired with FibroScan® (right lobe of liver) and Acoustic Radiation Force Impulse (right and left lobe of liver). We used Spearman's correlation to explore the relationship between FibroScan® and Acoustic Radiation Force Impulse scores. A Bland-Altman plot was used to evaluate bias between the mean percentage differences of FibroScan® and Acoustic Radiation Force Impulse scores. Univariable and multivariable analyses were used to assess how factors such as body mass index, age and gender influenced the agreement between liver stiffness measurements. Results: Bland-Altman showed the average (95% CI) percentage difference between FibroScan® and Acoustic Radiation Force Impulse scores was 27.5% (17.8, 37.2), p < 0.001. There was a negative correlation between the average and percentage difference of the FibroScan® and Acoustic Radiation Force Impulse scores ( r (95% CI) = -0.41 (-0.57, -0.21), p < 0.001), thus showing that percentage difference gets smaller for greater FibroScan® and Acoustic Radiation Force Impulse scores. Body mass index was the biggest influencing factor on differences between FibroScan® and Acoustic Radiation Force Impulse (r = 0.12 (0.01, 0.23), p = 0.05). Acoustic Radiation Force Impulse scores at segment 5/8 and the left lobe showed good correlation (r (95% CI) = 0.83 (0.75, 0.89), p < 0.001). Conclusion: FibroScan® and Acoustic Radiation Force Impulse had similar predictive values for the assessment of liver stiffness in patients with chronic hepatitis C infection; however, the level of agreement varied across lower and higher scores.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom.

PURPOSE: To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom. SETTING: Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD). DESIGN: Retrospective cross-sectional register-based study. METHODS: Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers. RESULTS: Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates. CONCLUSIONS: Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

Visual performance and subjective experience 3 months and 12 months after combined implantation of 2 new complementary continuous phase multifocal intraocular lenses.

PURPOSE: To assess the 3-month and 12-month postoperative visual performance and subjective quality of vision (QoV) after combined implantation of complementary continuous phase multifocal intraocular lenses (IOLs). SETTING: Private practice, United Kingdom. DESIGN: Case series. METHODS: The study enrolled 44 patients undergoing phacoemulsification with implantation of an Artis Symbiose Mid in the dominant eye and an Artis Symbiose Plus in the nondominant eye. Refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity, uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), electronic reading desk, and a QoV questionnaire were evaluated at 3 months and 12 months postoperatively. RESULTS: The mean binocular UDVA was -0.06 ± 0.08 logMAR and -0.07 ± 0.06 logMAR at 3 months and 12 months ( P = .097), respectively. The mean binocular UIVA was 0.03 ± 0.13 logMAR and 0.03 ± 0.10 logMAR ( P = 1.0), respectively. The mean binocular UNVA was 0.07 ± 0.10 logMAR and 0.07 ± 0.08 logMAR ( P = .875), respectively. There was a significant improvement in QoV for both day and night between 3 and 12 months, with a significant reduction in halos at 12 months. Spectacle independence was reported in 93.2% of cases at 12 months. CONCLUSIONS: The Artis Symbiose Mid and Plus IOL combined implantation provided an excellent range of uncorrected vision at 3 and 12 months. There was a significant improvement in QoV and less halos at 12 months. This IOL combination provided very high rates of complete spectacle independence.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 12, Risk factors for suprachoroidal haemorrhage during cataract surgery.

OBJECTIVE: To establish the incidence of acute intraoperative suprachoroidal haemorrhage (AISH) during cataract surgery and identify the risk factors for this complication. METHODS: Data from the Royal College of Ophthalmologists' National Ophthalmology Database was analysed. During the 11-year study period, from 01/04/2010 to 31/03/2021, 709 083 operations performed on 498 170 patients from 65 centres were eligible for inclusion. RESULTS: AISH occurred in 0.03% (204/709 083, approximately 1 in 3 500) of eligible cataract operations performed during the study period. Posterior capsule rupture was the risk factor most strongly associated with AISH (OR: 17.6, 95% CI: 12.4-24.9, p < 0.001). Other ocular risk factors identified were raised intraocular pressure (IOP) preoperatively (OR: 3.7, 95% CI: 2.5-5.5, p < 0.001), glaucoma (OR: 1.7, 95% CI: 1.2-2.4, p = 0.004). Risk increased with age and patients aged over 90 years were at greatest risk (OR: 6.7, 95% CI: 3.5-12.8, p < 0.001). The addition of intracameral anaesthetic when performing surgery under topical anaesthetic appears to be protective (OR: 0.5, 95% CI: 0.3-0.8, p = 0.003), compared to topical anaesthetic alone. There was a 16-fold increase in the incidence of vision loss when AISH occurred. CONCLUSIONS: The risk of AISH during modern cataract surgery is approximately 1 in 3 500 and is associated with a significant increase in the risk of vision loss should it occur. Posterior capsule rupture is the risk factor most strongly associated with AISH. Preoperative IOP control is a modifiable risk factor. The use of intracameral anaesthesia may reduce the risk of AISH.

Endoscopy training through the COVID-19 pandemic: maintaining procedural volumes and key performance standards.

Objective: Endoscopy departments have experienced considerable challenges in the provision of endoscopy services since the start of the COVID-19 pandemic. Several studies have reported a reduction of procedures performed by trainee endoscopists during the pandemic. The aim of this study was to assess the impact on colonoscopy training and quality in an academic centre throughout successive waves of the pandemic. Methods: This was a single-centre, retrospective, observational study comparing colonoscopies performed at a tertiary endoscopy centre in Ireland at different stages of the pandemic with those performed during a similar time frame prepandemic. Data were collected using electronic patient records. Primary outcomes were procedure volumes, adenoma detection rate and mean adenoma per procedure. Results: In the prepandemic period, 798 colonoscopies were performed. During the same period in 2020, 172 colonoscopies were performed. In 2021, during the third wave of the pandemic, 538 colonoscopies were performed. Percentages of colonoscopies performed by trainees were 46.0% (n=367) in 2019, 25.6% (n=44) in 2020 and 45.2% (n=243) in 2021. Adenoma detection rate was 21.3% in 2019, 38.6% in 2020 and 23.9% in 2021. Mean adenoma per procedure was 0.45 in 2019, 0.86 in 2020 and 0.49 in 2021. Caecal intubation rate was 90.74% in 2019, 90.9% in 2020 and 95.88% in 2021. Conclusion: The COVID-19 pandemic initially had a negative impact on overall colonoscopy volumes and training. Despite a reduction in procedural volume, key performance standards were maintained by trainees. Maintenance of hands-on training is essential to allow trainees achieve and retain competency in endoscopy.

The Effects of High Energy Capsulotomy on Aqueous Cytokine Profiles and Pupil Size During Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To assess whether aqueous cytokine profiles and pupil size are altered when high capsulotomy energy is used in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS), and if preoperative use of a topical non-steroidal anti-inflammatory drug (NSAID) has an effect on this. METHODS: This prospective study recruited 83 eyes (63 patients) that were allocated to four treatment groups: conventional phacoemulsification (n = 20 eyes); FLACS with 90% capsulotomy energy without NSAID pretreatment (n = 20 eyes); FLACS with 90% capsulotomy energy with NSAID pre-treatment (n = 21 eyes); and FLACS with 150% capsulotomy energy with NSAID pretreatment (n = 22 eyes). Aqueous humor was collected before and after phacoemulsification to assess cytokine profiles. Pupil size was measured before and after laser capsulotomy. RESULTS: FLACS increased aqueous concentrations of pros-taglandin E2 (PGE2), interferon γ (IFN-γ), and interleukin 6 (IL-6) compared to conventional phacoemulsification. However, when increasing capsulotomy energy from 90% to 150% (with topical NSAID pretreatment), there was no significant increase in aqueous concentrations of PGE2 (37.7 ± 21.7 vs 33.6 ± 27.6 pg/mL, P = .99), IFN-γ (3.6 ± 1.1 vs 3.6 ± 0.8 pg/mL, P = .99), or IL-6 (7.1 ± 2.9 vs 6.3 ± 2.4 pg/mL, P = .99). For 90% and 150% capsulotomy energy, there was significant miosis following laser capsulotomy. Increased PGE2 concentration was significantly correlated with a reduction in pupil area (r = -0.58, P < .001) and pupil diameter (r = -0.57, P < .001). However, when a topical NSAID was given preoperatively, there was no difference in the degree of miosis between the 90% and 150% capsulotomy energy groups. CONCLUSIONS: Pretreatment with a topical NSAID prevented a rise in PGE2, IFN-γ, and IL-6 levels and excessive miosis when a higher capsulotomy energy was used. When a topical NSAID is used preoperatively, it is safe to use higher capsulotomy energy settings (with a low pulse energy femtosecond laser system) to achieve a satisfactory capsulotomy. [J Refract Surg. 2022;38(9):587-594.].

Visual and Refractive Outcomes Following Exchange of an Opacified Multifocal Intraocular Lens.

Purpose: To assess the visual and refractive outcomes following exchange of an opacified multifocal intraocular lens (IOL). Patients and Methods: A consecutive series of 37 eyes (31 patients) that underwent IOL exchange between November 2015 and May 2021 were included in this study. The indication for surgery in all cases was opacification of a multifocal IOL. Outcome measures included design and anatomical location of the secondary IOL, intraoperative and postoperative complications, visual acuity and refractive accuracy. Results: An opacified Lentis Mplus multifocal IOL was explanted from all eyes and replaced with a monofocal IOL in 21 eyes (57%) and multifocal IOL in 16 eyes (43%). Secondary IOLs were implanted in the capsular bag or sulcus or were iris-fixated. IOL exchange was performed at a mean interval of 7 years after the primary surgery. Anterior vitrectomy was required for vitreous prolapse in 9 eyes (24%). Mean corrected distance visual acuity (CDVA) postoperatively was -0.02 ± 0.08 logMAR for eyes with a monofocal secondary IOL and 0.02 ± 0.08 logMAR for eyes with a multifocal secondary IOL. Mean refractive prediction error was -0.57 ± 0.67 D in the multifocal-monofocal group and -0.33 ± 0.59 D in the multifocal-multifocal group. Conclusion: An opacified multifocal IOL can be exchanged for a monofocal or multifocal IOL, depending on available capsular support and the patient's desired refractive outcome. Vitreous prolapse requiring anterior vitrectomy is the most common intraoperative complication. An improvement in visual acuity and a low postoperative complication rate were achieved in this cohort of patients.

Surgical planning during a pandemic: Identifying patients at high risk of severe disease or death due to COVID-19 in a cohort of patients on a cataract surgery waiting list.

BACKGROUND: The delivery of cataract surgery during the COVID-19 pandemic is challenging because of the risk of nosocomial SARS-CoV-2 infection when patients attend hospital for elective care. In order to ascertain the risk to patients awaiting cataract surgery, this study aimed to identify the presence of systemic comorbidities that are associated with a high risk of severe disease or death due to COVID-19. METHODS: A prospective study of 315 patients (630 eyes) was conducted from 3rd June to 31st July 2020. An electronic health record was used to identify any systemic comorbidities that would render a patient 'clinically extremely vulnerable' to COVID-19, as outlined by the Department of Health for Northern Ireland. Patient demographics, best-corrected visual acuity (VA) and risk of postoperative anisometropia were also recorded. RESULTS: The median age of patients awaiting cataract surgery was 76 years (range 22-97). Of the 315 patients, 72% were aged over 70 and 16% were aged over 85. A systemic comorbidity that would confer high risk status was identified in 21% of patients. This high risk status was attributable to severe respiratory disease, cancer, and immunosuppression therapies in the majority of cases. The high risk group were younger than those deemed non-high risk, but there were no significant differences with respect to gender, anticipated degree of surgical difficulty, VA, or whether the patient was undergoing first or second eye surgery. Of those patients awaiting first eye cataract surgery, the mean VA in the listed eye was 0.84 logMAR and 39% (70/179) had a VA <0.3 logMAR (6/12 Snellen acuity) in their fellow eye. 57% of patients were awaiting first eye surgery, and 32% of those patients would be at risk of symptomatic anisometropia postoperatively. CONCLUSION: One-fifth of patients awaiting cataract surgery were found to be at high risk of severe disease or death from COVID-19 and these patients may experience delays in their surgical care. Additional planning is required in order to minimise the morbidity associated with delayed cataract surgery.

Visual outcomes and patient satisfaction 1 and 12 months after combined implantation of extended depth of focus and trifocal intraocular lenses.

PURPOSE: To assess the 1-month and 12-month postoperative visual performance and subjective outcomes following combined implantation of an extended depth of focus (EDOF) intraocular lens (IOL) and a trifocal IOL. METHODS: The study enrolled consecutive patients undergoing refractive lens extraction or cataract surgery with combined implantation of an EDOF IOL (dominant eye) and trifocal IOL. Uncorrected (UDVA) and best-corrected (CDVA) distance visual acuities, uncorrected intermediate (UIVA) and near (UNVA) visual acuities, and subjective questionnaires were evaluated 1 month and 12 months postoperatively. RESULTS: The study enrolled 58 consecutive patients. Binocular UDVA, UIVA and UNVA were - 0.08 ± 0.07 logMAR, 0.15 ± 0.14 logMAR and 0.17 ± 0.11 logMAR at 1 month, compared to - 0.09 ± 0.06 logMAR (P = .323), 0.11 ± 0.10 logMAR (P = .030) and 0.13 ± 0.10 logMAR (P = 0.008) at 12 months. Satisfaction was high with 93.1% of patients fulfilled or more than fulfilled postoperatively, and 84.5% and 86.3% reported spectacle independence for near at the respective postoperative assessments. The mean daytime and nighttime quality of vision (QoV) scores were 9.12 ± 0.94 and 7.88 ± 1.74 at 1 month, compared to 9.24 ± 0.78 (P = .183) and 8.26 ± 1.38 (P = .043) at 12 months. CONCLUSIONS: This IOL combination provides good unaided visual acuity at 1 and 12 months postoperatively, with high functional vision and postoperative satisfaction reported at 1 and 12 months. However, a significant improvement in overall nighttime QoV at the 12 months assessment was found.

Clinical Applications of In Vivo Confocal Microscopy in Keratorefractive Surgery.

PURPOSE: To review the contribution of in vivo confocal microscopy (IVCM) to the understanding of corneal wound healing following refractive surgery, and its role in the diagnosis and management of complications arising from keratorefractive procedures. METHODS: Review of the basic science and clinical literature relating to the study of keratorefractive surgical procedures using IVCM. RESULTS: Extensive research using IVCM has generated a comprehensive understanding of tissue responses after corneal refractive surgery. Epithelial thickness and stromal keratocyte density can be quantified postoperatively and studied longitudinally. Corneal nerve loss and subsequent reinnervation has been characterized and differs significantly between laser refractive techniques. IVCM has also been used to study complications arising from postoperative inflammation (diffuse lamellar keratitis, central toxic keratopathy, ring keratitis, and ectasia), infection (microbial keratitis), and neuropathy (dry eye and neuralgia). This imaging technique can have a critical role in the diagnosis of these complications and subsequent monitoring of treatment response. Manual processing of IVCM images is time-consuming and there may be significant interobserver and intraobserver variability with poor repeatability. However, increasing automation and the use of artificial intelligence is improving the speed and accuracy of image analysis. CONCLUSIONS: IVCM has historically been confined to a research setting because image capture and subsequent processing was extremely labor intensive. However, advances in both hardware and software capabilities promise to allow the use of IVCM in routine clinical practice. Real-time evaluation of the cornea at a cellular level will be particularly useful in patients with inflammatory, infectious, or neuropathic complications of keratorefractive surgery. [J Refract Surg. 2021;37(7):493-503.].

Primary Adnexal Signet-Ring Cell/Histiocytoid Carcinoma.

An 84-year-old man presented with a 2-year history of a progressive left-sided ptosis. Examination demonstrated a mechanical ptosis and concentric constriction of the palpebral aperture. CT imaging revealed demonstrated diffuse soft tissue infiltration of the upper and lower eyelids with extension into the anterior orbit. This case was diagnostically challenging because of a history of multiple other primary tumors. However, clinicoradiologic and histopathologic findings were consistent with a diagnosis of primary adnexal signet-ring cell/histiocytoid carcinoma. The patient underwent surgical excision but local recurrence was noted 2 months postoperatively.

Over 12 Years Single Institutional Experience Performing Percutaneous Hepatic Perfusion for Unresectable Liver Metastases.

Patients with unresectable hepatic metastases, from uveal or ocular melanoma, are challenging to treat with an overall poor prognosis. Although over the past decade significant advances in systemic therapies have been made, metastatic disease to the liver, especially from uveal melanoma, continues to be a poor prognosis. Percutaneous hepatic perfusion (PHP) is a safe, viable treatment option for these patients. PHP utilizes high dose chemotherapy delivered directly to the liver while minimizing systemic exposure and can be repeated up to 6 times. Isolation of the hepatic vasculature with a double-balloon catheter allows for high concentration cytotoxic therapy to be administered with minimal systemic adverse effects. A detailed description of the multidisciplinary treatment protocol used at an institution with over 12 years of experience is discussed and recommendations are given. A dedicated team of a surgical or medical oncology, interventional radiology, anesthesiology and a perfusionist allows PHP to be repeatedly performed as a safe treatment strategy for unresectable hepatic metastases.

Endothelial Cells Derived From Patients With Diabetic Macular Edema Recapitulate Clinical Evaluations of Anti-VEGF Responsiveness Through the Neuronal Pentraxin 2 Pathway.

Diabetic macular edema (DME) remains a leading cause of vision loss worldwide. DME is commonly treated with intravitreal injections of vascular endothelial growth factor (VEGF)-neutralizing antibodies. VEGF inhibitors (anti-VEGFs) are effective, but not all patients fully respond to them. Given the potential side effects, inconvenience, and high cost of anti-VEGFs, identifying who may not respond appropriately to them and why is essential. Herein we determine first the response to anti-VEGFs, using spectral-domain optical coherence tomography scans obtained from a cohort of patients with DME throughout the 1st year of treatment. We found that fluid fully cleared at some time during the 1st year in 28% of eyes ("full responders"); fluid cleared only partly in 66% ("partial responders"); and fluid remained unchanged in 6% ("nonresponders"). To understand this differential response, we generated induced pluripotent stem cells (iPSCs) from full responders and nonresponders, from subjects with diabetes but no DME, and from age-matched volunteers without diabetes. We differentiated these iPSCs into endothelial cells (iPSC-ECs). Monolayers of iPSC-ECs derived from patients with diabetes showed a marked and prolonged increase in permeability upon exposure to VEGF; the response was significantly exaggerated in iPSC-ECs from nonresponders. Moreover, phosphorylation of key cellular proteins in response to VEGF, including VEGFR2, and gene expression profiles, such as that of neuronal pentraxin 2, differed between full responders and nonresponders. In this study, iPSCs were used in order to predict patients' responses to anti-VEGFs and to identify key mechanisms that underpin the differential outcomes observed in the clinic. This approach identified NPTX2 as playing a significant role in patient-linked responses and as having potential as a new therapeutic target for DME.

PRAGMATISM OF RANDOMIZED CLINICAL TRIALS ON RANIBIZUMAB FOR THE TREATMENT OF DIABETIC MACULAR EDEMA: Impact on Clinical Outcomes.

PURPOSE: To evaluate the pragmatism and generalizability of randomized clinical trials (RCTs) on ranibizumab for diabetic macular edema and determine whether clinical outcomes would differ based on whether or not patients fulfill the eligibility criteria of these RCTs. METHODS: Pragmatism and generalizability of three RCTs on ranibizumab for diabetic macular edema (DRCRnet Protocols I and T, and RESTORE) were rated using the PRECIS-2 tool. A cohort of consecutive patients with diabetic macular edema was assessed to determine whether clinical outcomes differed based on whether or not patients met the RCT eligibility criteria. Univariable and multivariable regression analyses, adjusted for baseline best-corrected visual acuity, central retinal thickness and number of injections received, were used. RESULTS: All RCTs were rated as being more pragmatic than explanatory, with DRCRnet trials being the most pragmatic. Of the 216 eyes (176 patients) included in the cohort, 63% would have met eligibility criteria for Protocol T, 61% for Protocol I, and 56% for RESTORE. When adjusted for best-corrected visual acuity, central retinal thickness, and number of ranibizumab injections received, there were no statistically significant differences in best-corrected visual acuity or central retinal thickness found between "eligible" and "ineligible" patients. CONCLUSION: Randomized clinical trials evaluating ranibizumab for diabetic macular edema were more pragmatic than explanatory. "Ineligible" patients still benefited from ranibizumab therapy.

In vivo diagnosis of intraocular osseous metaplasia in neovascular age-related macular degeneration.

A 75-year-old man presented with deterioration of right eye vision for 6 months. He had no relevant medical history. Fundus examination revealed subretinal fluid, fibrosis, and subretinal hemorrhages. Ocular coherence tomography of the right macula illustrated an underlying subretinal lesion with internal lamellae, resembling trabecular bone elsewhere in the body. Bruch's membrane was clearly intact beneath the lesion, indicating an extrachoroidal location. The lesion appeared highly reflective on B-scan ultrasonography, consistent with ossification. Although initially misdiagnosed as choroidal osteoma, this lesion represents in-vivo intraocular osseous metaplasia at the site of neovascular age-related macular degeneration. The authors believe that similar lesions may have been misdiagnosed as "atypical" osteoma caused by failure to identify their extrachoroidal location.

Fenofibrate for Diabetic Retinopathy.

Fenofibrate is a safe and inexpensive orally administered fibric acid derivative conventionally used to treat dyslipidemia. Two large randomized clinical trials, the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) studies, demonstrated the benefit of oral fenofibrate in the treatment of patients with type 2 diabetes and diabetic retinopathy (DR), including reduced disease progression and need for laser treatment for diabetic macular edema and proliferative diabetic retinopathy. These findings are supported by results of experimental studies, which have demonstrated beneficial effects of fenofibrate ameliorating retinal vascular leakage and leukostasis, downregulating vascular endothelial growth factor, and reducing endothelial cell and pericyte loss, among others; all of these are characteristic features of DR. In spite of this evidence, fenofibrate is not prescribed routinely for treating patients with diabetes and DR. In FIELD and ACCORD studies, retinopathy was not the primary outcome and this may explain, at least partly, its lack of use for this indication. New trials are now underway to specifically address the effects of fenofibrate in DR; these trials will provide additional and robust data that may support current evidence favoring the use of fenofibrate in this common microvascular complication of diabetes.

Vitreomacular interface abnormalities in patients with diabetic macular oedema and their implications on the response to anti-VEGF therapy.

PURPOSE: To determine whether the presence of vitreomacular interface abnormalities (VMIA) in patients with diabetic macular oedema (DMO) modifies the response to ranibizumab. METHODS: Medical records and spectral-domain optical coherence tomography (SD-OCT) scans of consecutive patients with centre-involving DMO initiating therapy with ranibizumab between December 2013 and March 2014 at the Belfast Health and Social Care Trust were reviewed. Patients were identified through an electronic database. Demographics; systemic baseline characteristics; history of previous ocular surgery/laser; best-corrected visual acuity (BCVA), central retinal thickness (CRT) and stage of retinopathy at presentation; and BCVA, CRT and presence/absence of fluid at the last follow-up were recorded. OCT scans were reviewed by a masked investigator who graded them for the presence/absence of VMIA at baseline and during follow-up and for the change in the posterior hyaloid face during follow-up. The association between (1) VMIA at baseline and (2) the change in the posterior hyaloid face during the follow-up and functional/anatomical outcomes was evaluated. RESULTS: One hundred forty-six eyes of 100 patients (mean age 63.5 years) followed for a mean of 9 months (range 2-14 months; only 9/146 dropped to follow-up before month 6) were included. Statistically significant differences were observed at baseline in BCVA (p = 0.007), previous macular laser and panretinal photocoagulation (PRP) (p = 0.006) and previous cataract surgery (p = 0.01) between eyes with and without VMIA, with better levels of vision, higher frequency of macular laser and lower frequency of PRP in eyes where no VMIA was present. Multivariable regression analysis did not disclose any statistically significant associations between VMIA at baseline or change in the posterior hyaloid face during the follow-up and functional and anatomical outcomes following treatment. CONCLUSION: VMIA are associated with worse presenting vision in patients with DMO; VMIA or change in the posterior hyaloid face during the follow-up did not modify the response to ranibizumab in this study.

Pneumatic retinopexy: patient selection and specific factors.

Pneumatic retinopexy is a minimally invasive, non-incisional procedure for repairing retinal detachment. This procedure is associated with reduced morbidity, reduced cost and faster postoperative recovery compared to pars plana vitrectomy and scleral buckling. Superior visual acuity outcomes have also been reported. Intraoperative complications are primarily related to the intraocular pressure rise caused by gas injection, or the misdirection of the gas. There is a low rate of postoperative complications. Anatomic success rates of over 90% can be achieved when strict selection criteria are applied. However, a number of studies have revealed good outcomes in cases with expanded clinical indications. Pneumatic retinopexy is currently underutilized. With appropriate patient selection, a high success rate can be achieved, and therefore, this procedure has an important role in the armamentarium of the vitreoretinal surgeon.

Disease outcomes in a cohort of women in Ireland infected by hepatitis C-contaminated anti-D immunoglobulin during 1970s.

BACKGROUND & AIM: In the mid-1990s, a group of Rh negative women was diagnosed with hepatitis C virus (HCV) genotype 1b infection, following administration of contaminated anti-D immunoglobulin in 1977-79. We aimed to describe their disease history and estimate the effect of selected host and treatment factors on disease progression. METHODS: We conducted a cohort study on the women infected with HCV. Information was collected from records at seven HCV treatment centres on demographics, treatment and health outcomes up to the 31st December 2013. We calculated cumulative incidence, case fatality, and sub hazard ratios (SHR) for disease progression using competing risks regression. RESULTS: Six hundred and eighty-two patients were included in the study. Among the chronically infected patients (n=374), 35% completed interferon-based antiviral treatment; 42% of whom had a sustained virological response. At the end of 2013, 19%, 1.9%, and 4.9% of chronically infected patients had developed cirrhosis, hepatocellular carcinoma, and liver-related death, respectively, compared with 10%, 0.8%, and 2.4% at the end of 2008. At the end of 2013, 321 (86%) of the chronically infected patients remained alive, 247 (77%) of whom were still chronically infected. Factors associated with increased cirrhosis rates included high alcohol intake (aSHR=4.9 [2.5-9.5]) and diabetes mellitus (aSHR=5.0 [2.9-8.8]). CONCLUSIONS: Development of liver-related outcomes accelerated with time, with the risk of cirrhosis, hepatocellular carcinoma, and liver-related death doubling in the last five years of follow-up, particularly in women with high alcohol consumption and diabetes mellitus. We recommend that patients with chronic HCV infection be advised of the additive harmful effect of alcohol, and that data be collected on this cohort after a further five years to analyse the effect of subsequent antiviral treatment during this rapidly evolving period in HCV treatment history. LAY SUMMARY: In the mid-1990s, a group of women were diagnosed with chronic hepatitis C virus (HCV) infection following receipt of contaminated anti-D immunoglobulin between 1977 and 1979 in Ireland. Seventy-two (19%) developed cirrhosis and 18 had died from liver-related causes (5%) after 36years of infection. Disease progression accelerated in the last five years of follow-up, particularly in women with diabetes mellitus and high alcohol consumption. We recommend that patients with chronic HCV infection be advised of the additive harmful effect of high alcohol consumption.