Arthrographis kalrae Keratitis Complicated by Endophthalmitis: A Case Report With Literature Review.

OBJECTIVES: To report the first case of Arthrographis kalrae keratitis complicated by endophthalmitis in the UK and to review the current literature. METHODS: A case report with literature review. RESULTS: A 65-year-old male patient, with a background of treated B-cell lymphoma and herpes simplex virus-related neurotrophic keratopathy, presented with a large infiltrative corneal ulcer in the right eye. The patient was immediately commenced on empirical antifungal treatment in view of the clinical suspicion of fungal keratitis (FK). The initial corneal scrape identified the organism as nonspecific "mold," and the identity of A. kalrae was subsequently confirmed using matrix-assisted laser/desorption ionization-time of flight-mass spectrometry (MALDI-TOF-MS). During the clinical course, the patient received topical, intrastromal, intracameral, and systemic antifungal treatment, repeat therapeutic corneal cross-linking treatment, and three penetrating keratoplasties. Although a temporary improvement was achieved with therapeutic corneal cross-linking treatment, the FK progressed relentlessly and was ultimately complicated by an endophthalmitis despite maximum medical and surgical treatment, eventuating in an enucleation. CONCLUSIONS: A. kalrae keratitis is an exceptionally rare clinical entity that poses significant therapeutic challenges. MALDI-TOF-MS serves as a useful diagnostic technique in identifying this rare organism. Although the literature suggested that A. kalrae keratitis may sometimes be controlled with antifungal medical treatment alone, this approach was proven to be futile in our immunocompromised patient with pre-existing neurotrophic keratopathy, suggesting that early surgical intervention such as therapeutic keratoplasty may be required in these cases.

Central Toxic Keratopathy After Contact Lens Wear and Mechanical Debridement: Clinical Characteristics, and Visual and Corneal Tomographic Outcomes.

OBJECTIVES: To highlight the clinical characteristics, and visual and corneal tomographic outcomes of central toxic keratopathy (CTK) after contact lens (CL) wear and mechanical debridement. METHODS: A retrospective observational case series with literature review. RESULTS: Four patients (4 eyes) were included in this study; 3 (75%) females, mean age 29.3±8.1 years. The mean follow-up was 13.5±7.5 months. Early central or paracentral stromal opacification, assuming an inverse dome-shaped pattern observed under anterior-segment optical coherence tomography, with corneal flattening (Kmean 40.4±1.3 D) and thinning (mean thinnest pachymetry=404.8±29.4 microns) were observed in all cases. All patients had a recent use of CL wear, with three after mechanical debridement for recurrent corneal erosion syndrome. None of them had any previous laser refractive surgery (LRS). The mean corrected distance visual acuity improved from 20/40 (ranged 20/25-20/50) initially to 20/30 (ranged 20/20-20/40) at final follow-up, and the outcome was not influenced by the use of topical steroids. A mean improvement of corneal flattening (+Kmean 1.2±1.2 D), thinning (+123.5±23.8 microns), and astigmatism (-3.0±2.7 D), via epithelial and stromal remodeling, was observed up to 15 months after CTK. Persisting reduced corneal sensation was noted in all patients at the final follow-up. CONCLUSIONS: Central toxic keratopathy is not an exclusive complication of LRS, and it may occur after CL wear and mechanical debridement. Our findings are similar to those of LRS-related CTK and toxic peripheral keratopathy. Awareness of the clinical associations and understanding of the clinical course and tomographic characteristics of CTK helps obviate unnecessary investigation and overtreatment. Further studies are required to elucidate the underlying pathogenesis of this rare clinical entity.

Polymicrobial Keratitis With Cryptococcus curvatus, Candida parapsilosis, and Stenotrophomonas maltophilia After Penetrating Keratoplasty: A Rare Case Report With Literature Review.

OBJECTIVES: To report the first case of fungal keratitis caused by Cryptococcus curvatus after penetrating keratoplasty (PK) in an immunocompetent patient and to describe its therapeutic challenge and long-term outcome. METHODS: An interventional case report. RESULTS: A 54-year-old female patient underwent right PK for lattice dystrophy. At 5-year post-PK, she developed a polymicrobial keratitis caused by Candida parapsilosis, and Stenotrophomonas maltophilia at the peripheral graft, which was successfully treated with topical antibiotic and antifungal drops. One year later, another fungal keratitis occurred which apparently resolved with antifungal treatment but recurred in an unusual fashion and required a repeat PK revealing the diagnosis of C. curvatus keratitis. This was confirmed by microbiological culture on Sabouraud dextrose agar, nuclear ribosomal repeat regional sequencing of the D1-D2 and internal transcribed spacer regions, and histopathological examination. Various topical, intracorneal, and systemic antifungal treatments had been attempted but failed to resolve the infection completely, necessitating a subsequent third PK. A further recurrence was noted 16-month post-third PK, which was eradicated with multiple topical and intracorneal antifungal treatment, and direct cryotherapy to the corneal abscess. No further recurrence of C. curvatus was noted at 4-year follow-up. CONCLUSIONS: Cryptococcus curvatus should be added to the known list of organisms capable of causing fungal keratitis. Our experience suggests that this type of organism could cause low-grade, grumbling infection, which may however be exceptionally difficult to treat. Long-term eradication of this rare fungal keratitis could be potentially achieved by intensive ocular and systemic antifungal treatment, repeat therapeutic keratoplasties, and focal cryotherapy.

Late-onset traumatic dislocation of laser in situ keratomileusis corneal flaps: a case series with many clinical lessons.

PURPOSE: To report three cases of late-onset (7-14 years postoperative) traumatic dislocation of laser in situ keratomileusis (LASIK) flaps with epithelial ingrowth that all had delayed surgical intervention. METHODS: A retrospective, interventional case series of three patients who underwent flap repositioning and mechanical debridement of epithelial ingrowth, all after an initial delayed diagnosis/treatment of dislocated LASIK flap. RESULTS: Visual improvement was noted in all three cases following LASIK flap repositioning and debridement of epithelial ingrowth; patient 1 improved from 20/800 corrected-distance-visual-acuity (CDVA) to 20/20 uncorrected-distance-visual-acuity (UDVA) postoperative (14 years post-LASIK, 5-week interval between injury and surgery), patient 2 improved from 20/50 CDVA to 20/20 CDVA (10 years post-LASIK, 4-month interval between injury and surgery) and patient 3 improved from 20/80 CDVA to 20/60 CDVA (7 years post-LASIK, 14-month interval between injury and surgery). Flap dislocation was not suspected or diagnosed in two patients during the first ophthalmic visit. Postoperative visual outcome was not influenced by the presenting vision but might be negatively affected by the delay in surgical intervention, the presence of preoperative central epithelial ingrowth and postoperative striae. CONCLUSIONS: This case series reported one of the longest documented intervals between LASIK and traumatic dislocation of LASIK flap with secondary epithelial ingrowth. Delayed diagnosis and management of flap dislocation after corneal trauma may potentially increase the risk of epithelial ingrowth, recalcitrant flap striae and visual impairment. The presence of late-onset epithelial ingrowth in patients with previous LASIK mandates careful examination for occult flap displacement.

Purtscher-like retinopathy associated with squamous cell carcinoma of the cervix.

PURPOSE: To describe a previously unreported case of Purtscher-like retinopathy secondary to severe acute renal failure associated with squamous cell carcinoma of the cervix. METHODS: This is a case report. RESULTS: A 31-year-old female presented with a week history of acute abdominal pain, vomiting and severe renal failure followed by a sudden onset of bilateral visual loss. Vision was hand movement in either eye with central scotoma. Ophthalmic examination demonstrated bilateral retinal thickening and whitening with intraretinal hemorrhages localized to the peripapillary area, consistent with the diagnosis of Purtscher-like retinopathy. Further systemic examination revealed bilateral hydronephrosis secondary to underlying undiagnosed cervical carcinoma. Patient was treated with a short course of high-dose steroids. At 2 months, patient vision remained poor despite the resolution of retinal edema and hemorrhages. CONCLUSIONS: This case serves as the first report of Purtscher-like retinopathy secondary to acute renal failure associated with cervical carcinoma, expanding the list of causes of Purtscher's or Purtscher-like retinopathies. In the presence of significant uremia and absence of previously known association, the authors postulate that the sudden surge of uremia causes increase of endothelin-1 (a potent vasoconstrictor), resulting in downstream endothelin-induced vasculopathy with subsequent occlusion of the pre-capillary arteriolar network.

Comparative Study of Primary SMILE, SMILE Enhancement, and Femtosecond Laser-Assisted LASIK on Higher Order Aberrations and Corneal Densitometry.

PURPOSE: To compare differences in corneal densitometry (CD) and higher order aberrations (HOAs) in eyes that underwent small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for the treatment of myopia and myopic astigmatism at postoperative months 3, 6, and 12, and to evaluate their changes in a separate cohort of eyes after SMILE enhancement. METHODS: In this prospective, randomized, paired-eye clinical trial, consecutive eligible participants were randomized to undergo SMILE or FS-LASIK in either eye. Main outcome measures were CD and HOAs preoperatively and at 3, 6, and 12 months postoperatively. A separate cohort of consecutive patients who had SMILE and underwent enhancement were also included for comparison. RESULTS: For CD, no significant differences were found between SMILE and FS-LASIK up to month 12. For HOA measured by wavefront aberrometry, both SMILE and FS-LASIK had an increase in total root mean square (RMS) HOAs, spherical aberration (SA), and vertical coma up to month 12. SMILE had an additional increase in vertical quatrefoil, and FS-LASIK had an increase in horizontal coma at month 12. FS-LASIK had higher SA than SMILE, whereas SMILE had higher vertical quatrefoil than FS-LASIK at month 12. Central and posterior zone CD had significantly decreased after SMILE enhancement compared to after primary SMILE up to 2 years after enhancement. RMS HOAs, lower order aberrations, and SA were all increased after SMILE enhancement compared to after primary SMILE. CONCLUSIONS: SMILE induced lower SA but higher vertical quatrefoil than FS-LASIK at 1 year. Both SMILE and FS-LASIK had similar increases in RMS HOAs and vertical coma up to 1 year. There were no differences in CD between both groups. SMILE enhancement additionally had decreased central and posterior CD but greater RMS HOAs and SA compared to primary SMILE. [J Refract Surg. 2024;40(5):e291-e303.].

Large language models approach expert-level clinical knowledge and reasoning in ophthalmology: A head-to-head cross-sectional study.

Large language models (LLMs) underlie remarkable recent advanced in natural language processing, and they are beginning to be applied in clinical contexts. We aimed to evaluate the clinical potential of state-of-the-art LLMs in ophthalmology using a more robust benchmark than raw examination scores. We trialled GPT-3.5 and GPT-4 on 347 ophthalmology questions before GPT-3.5, GPT-4, PaLM 2, LLaMA, expert ophthalmologists, and doctors in training were trialled on a mock examination of 87 questions. Performance was analysed with respect to question subject and type (first order recall and higher order reasoning). Masked ophthalmologists graded the accuracy, relevance, and overall preference of GPT-3.5 and GPT-4 responses to the same questions. The performance of GPT-4 (69%) was superior to GPT-3.5 (48%), LLaMA (32%), and PaLM 2 (56%). GPT-4 compared favourably with expert ophthalmologists (median 76%, range 64-90%), ophthalmology trainees (median 59%, range 57-63%), and unspecialised junior doctors (median 43%, range 41-44%). Low agreement between LLMs and doctors reflected idiosyncratic differences in knowledge and reasoning with overall consistency across subjects and types (p>0.05). All ophthalmologists preferred GPT-4 responses over GPT-3.5 and rated the accuracy and relevance of GPT-4 as higher (p<0.05). LLMs are approaching expert-level knowledge and reasoning skills in ophthalmology. In view of the comparable or superior performance to trainee-grade ophthalmologists and unspecialised junior doctors, state-of-the-art LLMs such as GPT-4 may provide useful medical advice and assistance where access to expert ophthalmologists is limited. Clinical benchmarks provide useful assays of LLM capabilities in healthcare before clinical trials can be designed and conducted.

Management of limbal stem cell deficiency by amnion-assisted conjunctival epithelial redirection using vacuum-dried amniotic membrane and fibrin glue.

PURPOSE: To study the outcome of a modified amnion-assisted conjunctival epithelial redirection (ACER) technique using vacuum-dried amnion (Omnigen) and fibrin glue for managing total limbal stem cell deficiency (LSCD). METHOD: A retrospective, interventional case series of all patients with total LSCD who underwent limbal stem cell transplant (LSCT) using the modified ACER procedure between 2016 and 2019. The outcome was defined as: (1) success: complete corneal re-epithelialisation without conjunctivalisation; (2) partial success: sub-total corneal re-epithelialisation with partial non-progressive conjunctivalisation sparing the visual axis and (3) failure: conjunctivalisation affecting the visual axis. RESULTS: Ten patients (six men), with a mean age of 46.2±18.4 years, were included. The mean follow-up was 23.0±13.9 months. Causes of LSCD were chemical eye injury (30%), congenital aniridia-related keratopathy (30%), ocular surface malignancy (20%), Steven-Johnson syndrome (10%) and contact lens overuse (10%). 50% were bilateral. The time from diagnosis to ACER (for acquired causes) was 45.6±44.4 months. 80% of patients achieved a complete/partial success following ACER and 20% of patients required repeat LSCT. Auto-LSCT was associated with a significantly higher chance of success than allo-LSCT (p=0.048). The mean best-corrected-visual-acuity (logMAR) improved significantly from 1.76±0.64 preoperatively to 0.94±0.94 at final follow-up (p=0.009). Omnigen was available off-the-shelf stored at room temperature and its transparency enabled visualisation of the healing epithelium beneath. CONCLUSION: LSCT using the modified ACER serves as an effective ocular surface reconstruction technique in managing total LSCD and improving vision. Vacuum-dried amnion provides advantages of easy handling, transparency and storage at room temperature.

Large language models in medicine.

Large language models (LLMs) can respond to free-text queries without being specifically trained in the task in question, causing excitement and concern about their use in healthcare settings. ChatGPT is a generative artificial intelligence (AI) chatbot produced through sophisticated fine-tuning of an LLM, and other tools are emerging through similar developmental processes. Here we outline how LLM applications such as ChatGPT are developed, and we discuss how they are being leveraged in clinical settings. We consider the strengths and limitations of LLMs and their potential to improve the efficiency and effectiveness of clinical, educational and research work in medicine. LLM chatbots have already been deployed in a range of biomedical contexts, with impressive but mixed results. This review acts as a primer for interested clinicians, who will determine if and how LLM technology is used in healthcare for the benefit of patients and practitioners.

Camellia sinensis solvent extract, epigallocatechin gallate and caffeine confer trophocidal and cysticidal effects against Acanthamoeba castellanii.

We examined the anti-acanthamoebic efficacy of green tea Camellia sinensis solvent extract (SE) or its chemical constituents against Acanthamoeba castellanii by using anti-trophozoite, anti-encystation, and anti-excystation assays. C. sinensis SE (625-5000 µg/mL) inhibited trophozoite replication within 24-72 h. C. sinensis SE exhibited a dose-dependent inhibition of encystation, with a marked cysticidal activity at 2500-5000 µg/mL. Two constituents of C. sinensis, namely epigallocatechin-3-gallate and caffeine, at 100 µM and 200 µM respectively, significantly inhibited both trophozoite replication and encystation. Cytotoxicity analysis showed that 156.25-2500 µg/mL of SE was not toxic to human corneal epithelial cells, while up to 625 µg/mL was not toxic to Madin-Darby canine kidney cells. This study shows the anti-acanthamoebic potential of C. sinensis SE against A. castellanii trophozoites and cysts. Pre-clinical studies are required to elucidate the in vivo efficacy and safety of C. sinensis SE.

Management of keratoconus: an updated review.

Keratoconus is the most common corneal ectatic disorder. It is characterized by progressive corneal thinning with resultant irregular astigmatism and myopia. Its prevalence has been estimated at 1:375 to 1:2,000 people globally, with a considerably higher rate in the younger populations. Over the past two decades, there was a paradigm shift in the management of keratoconus. The treatment has expanded significantly from conservative management (e.g., spectacles and contact lenses wear) and penetrating keratoplasty to many other therapeutic and refractive modalities, including corneal cross-linking (with various protocols/techniques), combined CXL-keratorefractive surgeries, intracorneal ring segments, anterior lamellar keratoplasty, and more recently, Bowman's layer transplantation, stromal keratophakia, and stromal regeneration. Several recent large genome-wide association studies (GWAS) have identified important genetic mutations relevant to keratoconus, facilitating the development of potential gene therapy targeting keratoconus and halting the disease progression. In addition, attempts have been made to leverage the power of artificial intelligence-assisted algorithms in enabling earlier detection and progression prediction in keratoconus. In this review, we provide a comprehensive overview of the current and emerging treatment of keratoconus and propose a treatment algorithm for systematically guiding the management of this common clinical entity.

Propranolol Ameliorates the Antifungal Activity of Azoles in Invasive Candidiasis.

The effectiveness of current antifungal therapies is hampered by the emergence of drug resistance strains, highlighting an urgent need for new alternatives such as adjuvant antifungal treatments. This study aims to examine the synergism between propranolol and antifungal drugs, based on the premise that propranolol is known to inhibit fungal hyphae. In vitro studies demonstrate that propranolol potentiates the antifungal activity of azoles and that the effect is more pronounced for propranolol-itraconazole combination. Using an in vivo murine systemic candidemia model, we show that propranolol-itraconazole combination treatment resulted in a lower rate of body weight loss, decreased kidney fungal bioburden and renal inflammation when compared to propranolol and azole treatment alone or untreated control. Altogether, our findings suggest that propranolol increases the efficacy of azoles against C. albicans, offering a new therapeutic strategy against invasive fungal infections.

Diagnostic performance of deep learning in infectious keratitis: a systematic review and meta-analysis protocol.

INTRODUCTION: Infectious keratitis (IK) represents the fifth-leading cause of blindness worldwide. A delay in diagnosis is often a major factor in progression to irreversible visual impairment and/or blindness from IK. The diagnostic challenge is further compounded by low microbiological culture yield, long turnaround time, poorly differentiated clinical features and polymicrobial infections. In recent years, deep learning (DL), a subfield of artificial intelligence, has rapidly emerged as a promising tool in assisting automated medical diagnosis, clinical triage and decision-making, and improving workflow efficiency in healthcare services. Recent studies have demonstrated the potential of using DL in assisting the diagnosis of IK, though the accuracy remains to be elucidated. This systematic review and meta-analysis aims to critically examine and compare the performance of various DL models with clinical experts and/or microbiological results (the current 'gold standard') in diagnosing IK, with an aim to inform practice on the clinical applicability and deployment of DL-assisted diagnostic models. METHODS AND ANALYSIS: This review will consider studies that included application of any DL models to diagnose patients with suspected IK, encompassing bacterial, fungal, protozoal and/or viral origins. We will search various electronic databases, including EMBASE and MEDLINE, and trial registries. There will be no restriction to the language and publication date. Two independent reviewers will assess the titles, abstracts and full-text articles. Extracted data will include details of each primary studies, including title, year of publication, authors, types of DL models used, populations, sample size, decision threshold and diagnostic performance. We will perform meta-analyses for the included primary studies when there are sufficient similarities in outcome reporting. ETHICS AND DISSEMINATION: No ethical approval is required for this systematic review. We plan to disseminate our findings via presentation/publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022348596.

Host Defense Peptides at the Ocular Surface: Roles in Health and Major Diseases, and Therapeutic Potentials.

Sight is arguably the most important sense in human. Being constantly exposed to the environmental stress, irritants and pathogens, the ocular surface - a specialized functional and anatomical unit composed of tear film, conjunctival and corneal epithelium, lacrimal glands, meibomian glands, and nasolacrimal drainage apparatus - serves as a crucial front-line defense of the eye. Host defense peptides (HDPs), also known as antimicrobial peptides, are evolutionarily conserved molecular components of innate immunity that are found in all classes of life. Since the first discovery of lysozyme in 1922, a wide range of HDPs have been identified at the ocular surface. In addition to their antimicrobial activity, HDPs are increasingly recognized for their wide array of biological functions, including anti-biofilm, immunomodulation, wound healing, and anti-cancer properties. In this review, we provide an updated review on: (1) spectrum and expression of HDPs at the ocular surface; (2) participation of HDPs in ocular surface diseases/conditions such as infectious keratitis, conjunctivitis, dry eye disease, keratoconus, allergic eye disease, rosacea keratitis, and post-ocular surgery; (3) HDPs that are currently in the development pipeline for treatment of ocular diseases and infections; and (4) future potential of HDP-based clinical pharmacotherapy for ocular diseases.

Translational and Regulatory Challenges of Corneal Endothelial Cell Therapy: A Global Perspective.

Cell therapies are emerging as a unique class of clinical therapeutics in medicine. In 2015, Holoclar (ex vivo expanded autologous human corneal epithelial cells containing stem cells) gained the regulatory approval for treating limbal stem cell deficiency after chemical eye burn. This has set a precedent in ophthalmology and in medicine, reinforcing the therapeutic promise of cell therapy. However, to generalize and commercialize cell therapies on a global scale, stringent translational and regulatory requirements need to be fulfilled at both local and international levels. Over the past decade, the Singapore group has taken significant steps in developing human corneal endothelial cell (HCEnC) therapy for treating corneal endothelial diseases, which are currently the leading indication for corneal transplantation in many countries. Successful development of HCEnC therapy may serve as a novel solution to the current global shortage of donor corneas. Based on the experience in Singapore, this review aims to provide a global perspective on the translational and regulatory challenges for bench-to-bedside translation of cell therapy. Specifically, we discussed about the characterization of the critical quality attributes (CQA), the challenges that can affect the CQA, and the variations in the regulatory framework embedded within different regions, including Singapore, Europe, and the United States. Impact statement Functional corneal endothelium is critical to normal vision. Corneal endothelial disease-secondary to trauma, surgery, or pathology-represents an important cause of visual impairment and blindness in both developed and developing countries. Currently, corneal transplantation serves as the current gold standard for treating visually significant corneal endothelial diseases, although limited by the shortage of donor corneas. Over the past decade, human corneal endothelial cell therapy has emerged as a promising treatment option for treating corneal endothelial diseases. To allow widespread application of this therapy, significant regulatory challenges will need to be systematically overcome.

Graft detachments in endothelial keratoplasty.

Graft detachment is the most common complication of endothelial keratoplasty. With the ongoing advancements in the field of endothelial keratoplasty, our understanding of risk factors of graft detachments and its management has been evolving. Various prevention measures have been described in literature including presoaking the donor graft, anterior chamber tamponade, venting incisions, sutures to prevent dislocation of graft. Management of a detached graft involves secondary interventions such as rebubbling, suturing and regrafts. In this review, we discuss graft detachment in different types of endothelial keratoplasty techniques including Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty; with emphasis on incidence, risk factors, preventive measures and their management.

Real-world experience of using ciclosporin-A 0.1% in the management of ocular surface inflammatory diseases.

PURPOSE: To report the real-world experience of using topical ciclosporin, Ikervis, in the management of ocular surface inflammatory diseases (OSIDs). METHODS: This was a retrospective study of patients treated with Ikervis for OSIDs at the Queen's Medical Centre, Nottingham, between 2016 and 2019. Relevant data, including demographics, indications, clinical parameters, outcomes and adverse events, were collected and analysed for patients who had completed at least 6 months follow-up. For analytic purpose, clinical outcome was categorised as 'successful' (resolved or stable disease), 'active disease' and 'drug intolerance'. RESULTS: 463 patients were included; mean age was 51.1±21.6 years, with a 59.0% female predominance. Mean follow-up was 14.6±9.2 months. The most common diagnosis was dry eye disease (DED; 322, 69.5%), followed by allergic eye disease (AED; 53, 11.4%) and ocular mucous membrane pemphigoid/Steven-Johnson syndrome (OMMP/SJS; 38, 8.2%). Successful treatment was achieved in 343 (74.1%) patients, with 44 (9.5%) requiring additional treatment and 76 (16.4%) reporting drug intolerance. The efficacy of Ikervis was highest in DED (264, 82.0%), followed by OMMP/SJS (25, 65.8%) and post-keratoplasty (7, 50.0%; p<0.001). Logistic regression analysis demonstrated age <70 years (p=0.007), AED (p=0.002) and OMMP/SJS (p=0.001) as significant predictive factors for Ikervis intolerance. AED and post-keratoplasty were 8.16 times (95% CI, 2.78 to 23.99) and 13.98 times (95% CI, 4.22 to 46.28), respectively, more likely to require additional treatment compared with DED. CONCLUSIONS: Ikervis is a useful steroid-sparing topical treatment for managing OSIDs in the real-world setting. Preparations with improved tolerability are needed to benefit a larger number of patients.

Application of artificial intelligence in cataract management: current and future directions.

The rise of artificial intelligence (AI) has brought breakthroughs in many areas of medicine. In ophthalmology, AI has delivered robust results in the screening and detection of diabetic retinopathy, age-related macular degeneration, glaucoma, and retinopathy of prematurity. Cataract management is another field that can benefit from greater AI application. Cataract  is the leading cause of reversible visual impairment with a rising global clinical burden. Improved diagnosis, monitoring, and surgical management are necessary to address this challenge. In addition, patients in large developing countries often suffer from limited access to tertiary care, a problem further exacerbated by the ongoing COVID-19 pandemic. AI on the other hand, can help transform cataract management by improving automation, efficacy and overcoming geographical barriers. First, AI can be applied as a telediagnostic platform to screen and diagnose patients with cataract using slit-lamp and fundus photographs. This utilizes a deep-learning, convolutional neural network (CNN) to detect and classify referable cataracts appropriately. Second, some of the latest intraocular lens formulas have used AI to enhance prediction accuracy, achieving superior postoperative refractive results compared to traditional formulas. Third, AI can be used to augment cataract surgical skill training by identifying different phases of cataract surgery on video and to optimize operating theater workflows by accurately predicting the duration of surgical procedures. Fourth, some AI CNN models are able to effectively predict the progression of posterior capsule opacification and eventual need for YAG laser capsulotomy. These advances in AI could transform cataract management and enable delivery of efficient ophthalmic services. The key challenges include ethical management of data, ensuring data security and privacy, demonstrating clinically acceptable performance, improving the generalizability of AI models across heterogeneous populations, and improving the trust of end-users.