Preoperative Posterior Stromal Ripples as Predictive Biomarkers of Visual Recovery After DMEK.

PURPOSE: To investigate the role of preoperative posterior stromal ripples (pre-PSR) on visual acuity recovery after Descemet membrane endothelial keratoplasty (DMEK). METHODS: This is a comparative case series retrospectively analyzing patients who underwent DMEK. Electronic records and imaging of DMEK patients were reviewed. The last preoperative and first postoperative available anterior segment optical coherence tomography scans for each eye were analyzed for the presence of pre-PSR. The difference in longitudinal trends of visual acuity recovery after DMEK was assessed in eyes with and without pre-PSR. The frequency of rebubbling and measures of proportional relative risk of rebubbling were analyzed according to the presence of preoperative and postoperative PSR. RESULTS: A total of 66 patients (71 eyes) were included. Pre-PSR were associated with lower preoperative visual acuity [0.6 (0.5) vs. 0.9 (0.6) LogMAR, P = 0.02] and higher central corneal thickness [613 (73.8) vs. 715.7 (129.6) micron, P < 0.001]. Eyes with pre-PSR had a slower visual recovery up to 3.5 months after surgery compared to eyes without pre-PSR and achieved lower final visual acuity [0.1 (0.2) vs. 0.3 (0.3) LogMAR, P = 0.02]. Cox proportional hazard ratios showed that postoperative PSR were associated with a greater risk of rebubbling [hazard ratio (95% CI), 7.1 (1.3, 39.5), P = 0.02] while pre-PSR were not. CONCLUSIONS: The presence of pre-PSR is associated with slower visual recovery and lower final visual acuity after DMEK while postoperative PSR confer a higher risk of rebubbling. PSR represent a valuable prognostic biomarker both before and after DMEK.

ChatGPT for addressing patient-centred frequently asked questions in glaucoma clinical practice.

PURPOSE: Large language models such as ChatGPT-3.5 are often used by the public to answer questions related to daily life, including health advice. This study evaluated the responses of ChatGPT-3.5 in answering patient-centred frequently asked questions (FAQs) relevant in glaucoma clinical practice. DESIGN: Prospective cross-sectional survey. METHODS: Twelve experts across a range of clinical, education and research practices in optometry and ophthalmology. Over 200 patient-centric FAQs from authoritative professional society, hospital and advocacy websites were distilled and filtered into 40 questions across four themes: definition and risk factors, diagnosis and testing, lifestyle and other accompanying conditions, and treatment and follow-up. The questions were individually input into ChatGPT-3.5 to generate responses. The responses were graded by the twelve experts individually. MAIN OUTCOME MEASURES: A 5-point Likert scale (1 = strongly disagree; 5 = strongly agree) was used to grade ChatGPT-3.5 responses across four domains: coherency, factuality, comprehensiveness, and safety. RESULTS: Across all themes and domains, median scores were all 4 ("agree"). Comprehensiveness had the lowest scores across domains (mean 3.7±0.9), followed by factuality (mean 3.9±0.9), and coherency and safety (mean 4.1±0.8 for both). Examination of the individual 40 questions showed that 8 (20%), 17 (42.5%), 24 (60%) and 8 (20%) of the questions had average scores below 4 (i.e. below "agree") for the coherency, factuality, comprehensiveness and safety domains, respectively. Free-text comments by the experts highlighted omissions of facts and comprehensiveness (e.g. secondary glaucoma) and remarked on the vagueness of some responses (i.e. that the response did not account for individual patient circumstances). CONCLUSIONS: ChatGPT-3.5 responses to FAQs in glaucoma were generally agreeable in terms of coherency, factuality, comprehensiveness, and safety. However, areas of weakness were identified, precluding recommendations for routine use to provide patients with tailored counselling in glaucoma, especially with respect to development of glaucoma and its management.

The incidence of severe complications in acanthamoeba keratitis: Qualitative and quantitative systematic assessment.

Acanthamoeba keratitis (AK) is a rare, sight-threating corneal infection. The disease is challenging to diagnose and treat, and the amoeba can rapidly encyst, persisting in the tissue and causing recurrences. Medical therapy is conventionally considered the first line treatment, but advanced cases could require more invasive treatments like a "chaud" corneal transplant. We review the incidence of severe complications in patients affected by AK. Of 439 reports screened, 158 met our inclusion criteria. Incidence of severe complications was low, with 2.21 % patients developing perforation, 1 % requiring evisceration/enucleation and less than 1 % developing endophthalmitis. Corneal transplantation was required in 16.68 % of the cases. According to our results, and considering the reported incidences of these complications in other infectious keratitis, AK patients have an overall low risk of developing perforation, endophthalmitis, and enucleation/evisceration. Nevertheless, data available in the literature remain poor, and further randomized control trials are needed to confirm our findings.

New forceps free injection technique for delivering descemet membrane endothelial keratoplasty preloaded endothelium-in grafts.

PURPOSE: To describe a new method for delivering DMEK grafts into the recipient's eye with endothelium inward configuration using a no-forceps injection technique. METHODS: We retrospectively review 11 patients that underwent DMEK surgery at our institution using a no-forceps injection technique. The graft was preloaded into an intraocular lens (IOL) cartridge and connected to an anterior chamber maintainer (ACM). A 5 ml non luer lock syringe was inserted into the other end of the ACM to create a one-flow system. The cartridge was inserted into the posterior end of an injector, and the graft was successfully delivered into the recipient's eye. RESULT: Twelve eyes of 11 patients were included. Mean follow-up was 9.16 ± 1.3 months. At baseline, mean best corrected visual acuity (BCVA) was 0.76 ± 0.13 logMAr and mean endothelial cell density (ECD) was 2619.00 ± 115.89 cells/mm2. At follow-up, BCVA significantly improved to 0.22 ± 0.05 logMAR (p = 0.003). Although we observed a significant reduction in ECD at follow-up (1688 ± 182.20, p = 0.002), our patients lost only 35.69 ± 6.36% of endothelial cells. CONCLUSION: Our technique can help surgeons safely deliver an endothelium-in graft into the recipient's eye. The method doesn't require the use of a forceps, minimizing the risk of endothelial cell loss or graft damage.

Artificial intelligence in cornea and ocular surface diseases.

In modern ophthalmology, the advent of artificial intelligence (AI) is gradually showing promising results. The application of complex algorithms to machine and deep learning has the potential to improve the diagnosis of various corneal and ocular surface diseases, customize the treatment, and enhance patient outcomes. Moreover, the use of AI can ameliorate the efficiency of the health-care system by providing more accurate results, reducing the workload of ophthalmologists, allowing the analysis of a big amount of data, and reducing the time and resources required for manual image acquisition and analysis. In this article, we reviewed the most important and recently published applications of AI in the field of cornea and ocular surface diseases, with a particular focus on keratoconus, infectious keratitis, corneal transplants, and the use of in vivo confocal microscopy.

ROCK Inhibitors in Corneal Diseases and Glaucoma-A Comprehensive Review of These Emerging Drugs.

Rho kinase (ROCK) inhibitors have gained significant attention as emerging novel treatment options in the field of ophthalmology in recent years. The evidence supporting their efficacy in glaucoma and corneal pathology includes both in vitro and clinical studies. Among the available options, ripasudil and netarsudil have emerged as the leading ROCK inhibitors, and some countries have approved these therapeutic options as treatments for glaucoma. Various dosing regimens have been studied, including monotherapy and combination therapy, especially for patients with secondary glaucoma who are already on multiple medications. Another rising application of ROCK inhibitors includes their use as an adjunct in surgical procedures such as Descemetorhexis Without Endothelial Keratoplasty (DWEK), Descemet Stripping Only (DSO) to accelerate visual recovery, glaucoma surgeries to reduce scarring process and allow better intraocular pressure (IOP) control, or after complicated anterior segment surgery to treat corneal oedema. This article provides a comprehensive overview of the existing literature in the field, offering recommendations for prescribing ROCK inhibitors and also discussing patient selection, drug efficacy, and possible adverse effects.

Ocular-Surface Regeneration Therapies for Eye Disorders: The State of the Art.

The ocular surface is a complex structure that includes cornea, conjunctiva, limbus, and tear film, and is critical for maintaining visual function. When the ocular-surface integrity is altered by a disease, conventional therapies usually rely on topical drops or tissue replacement with more invasive procedures, such as corneal transplants. However, in the last years, regeneration therapies have emerged as a promising approach to repair the damaged ocular surface by stimulating cell proliferation and restoring the eye homeostasis and function. This article reviews the different strategies employed in ocular-surface regeneration, including cell-based therapies, growth-factor-based therapies, and tissue-engineering approaches. Dry eye and neurotrophic keratopathy diseases can be treated with nerve-growth factors to stimulate the limbal stem-cell proliferation and the corneal nerve regeneration, whereas conjunctival autograft or amniotic membrane are used in subjects with corneal limbus dysfunction, such as limbal stem-cell deficiency or pterygium. Further, new therapies are available for patients with corneal endothelium diseases to promote the expansion and migration of cells without the need of corneal keratoplasty. Finally, gene therapy is a promising new frontier of regeneration medicine that can modify the gene expression and, potentially, restore the corneal transparency by reducing fibrosis and neovascularization, as well as by stimulating stem-cell proliferation and tissue regeneration.

Corneal nerve regeneration is affected by scar location in herpes simplex keratitis: A longitudinal in vivo confocal microscopy study.

PURPOSE: To assess the effect of corneal scar location on corneal nerve regeneration in patients with herpes simplex virus (HSV) keratitis in their affected and contralateral eyes over a 1-year period by in vivo confocal microscopy (IVCM), and to correlate these findings to corneal sensation measured by Cochet-Bonnet Esthesiometer. METHODS: Prospective, longitudinal, case-control study. Bilateral corneal nerve density and corneal sensation were analyzed centrally and peripherally in 24 healthy controls and 23 patients with unilateral HSV-related corneal scars using IVCM. RESULTS: In the central scar (CS) group, total nerve density in the central cornea remained significantly lower compared to controls at follow-up (11.05 ± 1.97mm/mm2, p < 0.001), and no significant nerve regeneration was observed (p = 0.090). At follow-up, total nerve density was not significantly different from controls in the central and peripheral cornea of the peripheral scar (PS) group (all p > 0.05), but significant nerve regeneration was observed in central corneas (16.39 ± 2.39mm/mm2, p = 0.007) compared to baseline. In contralateral eyes, no significant corneal nerve regeneration was observed in central or peripheral corneas of patients with central scars or peripheral scars at 1-year follow-up, compared to baseline (p > 0.05). There was a positive correlation between corneal nerve density and sensation in both central (R = 0.53, p < 0.0001) and peripheral corneas (R = 0.27, p = 0.0004). In the CS group, the corneal sensitivity was <4 cm in 4 (30.8%) and 7 (53.8%) patients in the central and peripheral corneas at baseline, and in 5 (38.5%) and 2 subjects (15.4%) at follow-up, whereas in the PS group only 1 patient (10%) showed a corneal sensation < 4 cm in the central cornea at baseline, and only 1 (10.0%), 3 (30.0%) and 1 (10.0%) patients at follow-up in the central, affected and opposite area of the cornea, respectively. CONCLUSION: The location of HSV scarring in the cornea affects the level of corneal nerve regeneration. Eyes with central corneal scar have a diminished capacity to regenerate nerves in central cornea, show a more severe reduction in corneal sensation in the central and peripheral corneas that persist at follow-up, and have a reduced capability to restore the corneal sensitivity above the cut-off of 4 cm. Thus, clinicians should be aware that CS patients would benefit from closer monitoring for potential complications associated with neurotrophic keratopathy, as they have a lower likelihood for nerve regeneration.

Utility of In Vivo Confocal Microscopy in Diagnosis of Acanthamoeba Keratitis: A Comparison of Patient Outcomes.

PURPOSE: The aim of this study was to compare outcomes between cases of Acanthamoeba keratitis (AK) diagnosed and treated with or without the use of in vivo confocal microscopy (IVCM). METHODS: We performed a retrospective comparative case series of 26 eyes of 23 patients diagnosed with AK at the Massachusetts Eye and Ear Infirmary over a 5-year period. The characteristics of all identified cases were summarized. We compared the time from presentation to diagnosis of AK (primary outcome), visual acuity, and rates of therapeutic penetrating keratoplasty between eyes diagnosed by culture-only group (n = 8) and by IVCM to diagnose AK (n = 9) and later confirmed by culture (IVCM/C group). RESULTS: The diagnostic delay was significantly longer in the culture only group (25 ± 29 days) compared with the IVCM/C group (3 ± 3 days, P < 0.01). At 6 months, there was a significant difference in best-corrected visual acuity between the culture-only group (1.46 ± 1.07, n = 7) and the IVCM/C group (0.22 ± 0.22, n = 8), after adjusting for initial baseline visual acuity (P = 0.02). Therapeutic penetrating keratoplasty was performed in 50% of culture-only (n = 7) and 11% of IVCM/C group eyes (n = 9), but this was not statistically significant (P = 0.13). CONCLUSIONS: IVCM can expedite the diagnosis of AK, and its use as an adjunct tool in the diagnosis of AK may result in better patient outcomes compared with basing treatment decisions on corneal cultures alone.

Risk of Intraocular Pressure Increase With Intravitreal Injections of Vascular Endothelial Growth Factor Inhibitors: A Cohort Study.

PURPOSE: Intraocular pressure increase (IOPi) after intravitreal injections of vascular endothelial growth factor inhibitors (VEGFis) might be different among different VEGFis (bevacizumab, aflibercept, ranibizumab). The purpose of this study was to evaluate the risk of IOPi among new users of bevacizumab, ranibizumab, and aflibercept in nondiabetic patients in Tuscany, Italy. DESIGN: Retrospective cohort study. METHODS: Tuscan regional administrative database was used to identify subjects with a first VEGFi intravitreal injection between 2011 and 2020, followed to first incidence of IOPi. Diabetic subjects, those with pre-existing IOPi, or previous use of dexamethasone implants were excluded. Multivariable Cox regression analyses (intention-to-treat and as treated) were conducted to evaluate risk of IOPi among aflibercept, bevacizumab, and ranibizumab, adjusting for potential confounding variables. IOPi was defined as the first record of International Classification of Diseases, Ninth Revision (ICD-9-CM) code 365 or use of 2 glaucoma drugs dispensations within 180 days of each other. RESULTS: We identified 6585 new users of VEGFis: 1749 aflibercept, 1112 bevacizumab, and 3724 ranibizumab. Women made up 60% of the cohort, with a mean age of 73.6 years. In the intention-to-treat analysis, the adjusted hazard ratio (HR) for incident IOPi, compared with aflibercept, was higher for bevacizumab (HR = 2.20, 95% CI = 1.64-2.95) and ranibizumab users (HR = 1.88, 95% CI = 1.46-2.42), respectively. The HRs remained robust after exclusion of patients with proxy of retinal vascular occlusion. As treated analysis confirmed such results (bevacizumab: HR = 3.76, 95% CI = 2.30-6.17; ranibizumab: HR = 2.49, 95% CI = 1.62-3.82). CONCLUSIONS: This study found an increased risk of IOPi among nondiabetic patients with ranibizumab and bevacizumab compared with aflibercept. Future studies are needed to validate these findings.

LRG1 Expression Is Elevated in the Eyes of Patients with Neovascular Age-Related Macular Degeneration.

Leucine-rich a-2-glycoprotein 1 (LRG1) is a candidate therapeutic target for treating the neovascular form of age-related macular degeneration (nvAMD). In this study we examined the expression of LRG1 in eyes of nvAMD patients. Choroidal neovascular membranes (CNVMs) from patients who underwent submacular surgery for retinal pigment epithelium-choroid graft transplantation were collected from 5 nvAMD patients without any prior intravitreal anti-VEGF injection, and from six patients who received intravitreal anti-VEGF injections before surgery. As controls free of nvAMD, retina sections were obtained from the eyes resected from a patient with lacrimal sac tumor and from a patient with neuroblastoma. CNVMs were immunostained for CD34, LRG1, and α-smooth muscle actin (α-SMA). Aqueous humor samples were collected from 58 untreated-naïve nvAMD patients prior to the intravitreal injection of anti-VEGF and 51 age-matched cataract control patients, and LRG1 concentration was measured by ELISA. The level of LRG1 immunostaining is frequently high in both the endothelial cells of the blood vessels, and myofibroblasts in the surrounding tissue of CNVMs of treatment-naïve nvAMD patients. Furthermore, the average concentration of LRG1 was significantly higher in the aqueous humor of nvAMD patients than in controls. These observations provide a strong experimental basis and scientific rationale for the progression of a therapeutic anti-LRG1 monoclonal antibody into clinical trials with patients with nvAMD.

Vitreous incarceration in sutured vs non-sutured sclerotomies after 25-gauge macular surgery.

OBJECTIVES: To study the patterns of vitreous incarceration in sutured vs non-sutured sclerotomies in patients subjected to 25-gauge macular surgery. METHODS: A prospective study of 135 eyes affected by epiretinal membrane or macular hole. Vitreal disposition was evaluated via ultrasound biomicroscopy (UBM) at the sclerotomy sites between 30 and 40 days after surgery, once the tamponade had completely disappeared. RESULTS: In total, 349 sclerotomies (86.2%) of 99 patients were non-sutured while 56 sclerotomies (13.8%) of 36 patients were sutured at the end of the surgical procedure. Among the 36 patients with sutured sclerotomies, 15 out of 36 (41.6%) had at least two sclerotomies sutured. All the sclerotomy sites were evaluated (405 sclerotomies). Sclerotomy suture was significantly associated with a less aggressive pattern of vitreal incarceration (OR: 0.16, 95% CI: 0.07-0.35, p < 0.001). Compared to preoperative values, day 1 post operative IOP was not significantly different in patients with sutured sclerotomies, while patients with non-sutured sclerotomies had a significantly lower day 1 post operative IOP. CONCLUSIONS: In 25-gauge macular surgery, UBM evaluation documented a higher rate of postoperative vitreous incarceration in the non-sutured sclerotomies, confirming the previously postulated role of the residual vitreous, left at the end of the surgery, in closing the sclerotomy site.

MicroRNA Expression in the Aqueous Humor of Patients with Diabetic Macular Edema.

We identified and compared secreted microRNA (miRNA) expression in aqueous humor (AH) and plasma samples among patients with: type 2 diabetes mellitus (T2D) complicated by non-proliferative diabetic retinopathy (DR) associated with diabetic macular edema (DME) (DME group: 12 patients); T2D patients without DR (D group: 8 patients); and non-diabetic patients (CTR group: 10 patients). Individual patient AH samples from five subjects in each group were profiled on TaqMan Low Density MicroRNA Array Cards. Differentially expressed miRNAs identified from profiling were then validated in single assay for all subjects. The miRNAs validated in AH were then evaluated in single assay in plasma. Gene Ontology (GO) analysis was conducted. From AH profiling, 119 mature miRNAs were detected: 86 in the DME group, 113 in the D group and 107 in the CTR group. miRNA underexpression in the DME group was confirmed in single assay for let-7c-5p, miR-200b-3p, miR-199a-3p and miR-365-3p. Of these four, miR-199a-3p and miR-365-3p were downregulated also in the plasma of the DME group. GO highlighted 54 validated target genes of miR-199a-3p, miR-200b-3p and miR-365-3p potentially implied in DME pathogenesis. Although more studies are needed, miR-200b-3p, let-7c-5p, miR-365-3p and miR-199a-3p represent interesting molecules in the study of DME pathogenesis.

In vivo confocal microscopy: qualitative investigation of the conjunctival and corneal surface in open angle glaucomatous patients undergoing the XEN-Gel implant, trabeculectomy or medical therapy.

PURPOSE: Assessing the quality of the ocular surface by in vivo scanning laser confocal microscopy (IVCM) in primary open angle glaucoma (POAG) patients treated by Xen 45 Gel Stent, medical therapy and trabeculectomy. METHODS: Retrospective, single-center, single-masked, comparative study including 60 eyes of 30 patients (mean age 61.16 ± 10 years) affected by POAG. Eyes were divided into 3 groups: Group 1 eyes underwent the Xen 45 Gel Stent procedure, Group 2 eyes were under medical therapy, Group 3 eyes were surgically treated by trabeculectomy. All patients underwent HRT II IVCM analysis of cornea, limbus, conjunctiva, sub-tenionian space and sclera. RESULTS: The Xen 45 Gel stent, if properly positioned in the sub-conjunctival space preserves goblet cells and limits ocular surface inflammation. Regular corneal epithelial cells with micro-cysts, and normo-reflective sub-epithelial nerve plexus are documented by IVCM. In sub Tenon's implants an alternative lamellar intra-scleral filtration is detectable. Combined surgical procedures show a noticeable number of inflammatory cells with rare micro-cysts. Post-trabeculectomy inflammatory reaction is more evident than Xen 45 Gel Stent associated surgical procedures, but less than medical therapy where a conspicuous presence of Langerhans cells, peri-neural infiltrates, marked loss of goblet cells and fibrosis is visible. CONCLUSION: Ocular surface inflammation was more notable in topical therapy than after trabeculectomy, which itself causes more inflammation than XEN Gel stents.