Efficacy and safety of intravitreal faricimab for neovascular age-related macular degeneration: a systematic review and meta-analysis.

We conducted a systematic review and meta-analysis to evaluate the visual, anatomical, and safety outcomes of the intravitreal faricimab, a novel vascular endothelial growth factor (VEGF)/angiopoietin-2 (Ang-2) bispecific agent, in neovascular age-related macular degeneration (nAMD) patients. The follow-up times in the included studies ranged from a minimum of 36 weeks to a maximum of 52 weeks. EMBASE, Ovid-Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, the WHO ICTRP, ClinicalTrial.gov, the EU Clinical Trials Register, and Chinese Clinical Trial Registry (ChiCTR) were searched (The last literature search was performed on August 17, 2023) for randomized controlled trials (RCTs) comparing faricimab with control groups for neovascular age-related macular degeneration (nAMD). The risk of bias for eligible RCTs was independently assessed using the Cochrane Risk of Bias Tool by two authors (W.-T.Y. and C.-S.W.). The meta-analysis was conducted using Review Manager 5.4 software. The mean best corrected visual acuity (BCVA), central subfield thickness (CST), total choroidal neovascularization (CNV) area, and total lesion leakage were analyzed as continuous variables and the outcome measurements were reported as the weighted mean difference (WMD) with a 95% confidence interval (CI). The ocular adverse events and ocular serious adverse events were analyzed as dichotomous variables and the outcome measurements were analyzed as the odds ratios (ORs) with a 95% CI. Random-effects model was used in our study for all outcome synthesizing due to different clinical characteristics. Four RCTs with 1,486 patients were eligible for quantitative analysis. There was no statistically significant difference between intravitreal faricimab and anti-VEGF in BCVA [weighted mean difference (WMD) = 0.47; 95% CI: (- 0.17, 1.11)]. The intravitreal faricimab group showed numerically lower CST [WMD = - 5.96; 95% CI = (- 7.11, - 4.82)], total CNV area [WMD = - 0.49; 95% CI = (- 0.68, - 0.30)], and total lesion leakage [WMD = - 0.88; 95% CI = (- 1.08, - 0.69)] after intravitreal therapy compared with the intravitreal anti-VEGF group. There were no statistically significant differences between intravitreal faricimab and anti-VEGF in ocular adverse events (AEs) [pooled odds ratio (OR) = 1.10; 95% CI = (0.81, 1.49)] and serious adverse events (SAEs) [pooled OR = 0.84; 95% CI = (0.37, 1.90)]. The intravitreal bispecific anti-VEGF/angiopoietin 2 (Ang2) antibody faricimab with a extended injection interval was non-inferior to first-line anti-VEGF agents in BCVA. It was safe and had better anatomical recovery. Large, well-designed RCTs are needed to explore the potential benefit of extended faricimab for nAMD. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022327450).

TEN-YEAR LONGITUDINAL MORPHOLOGIC CHANGES IN DOME-SHAPED MACULAS IN HIGHLY MYOPIC EYES.

PURPOSE: To determine the longitudinal changes in the morphologic features of dome-shaped macula in highly myopic eyes. METHODS: Patients with a dome-shaped macula and high myopia (spherical equivalent <-8 diopters [D] or axial length ≥26.5 mm) were retrospectively studied. The medical records, optical coherence tomographic images, and ultra-widefield optical coherence tomography images were analyzed. RESULTS: A total of 113 eyes of 82 patients were studied with a mean follow-up of 122.32 ± 6.36 months. During the follow-up, the mean dome height was significantly increased from 181.51 ± 105.55 to 209.85 ± 130.84 µ m ( P < 0.001). There was also a significant increase in the axial length (30.83 ± 1.82-31.16 ± 1.86 mm; P < 0.001). Subgroup analyses showed that the dome height increased more than 50 µ m in 78 (69%) eyes, decreased in 23 (20%) eyes, and was stable in 12 (11%) eyes. The change in the axial lengths was significantly greater in the increased dome height group than in the decreased and stable dome height groups ( P = 0.042). Multivariable analysis showed that the greater axial length change (OR, 8.73; P = 0.017) and horizontal type dome-shaped macula (OR, 4.14; P = 0.026) were significantly associated with an increase in dome height. CONCLUSION: The direction of change in the dome-shaped macula height varies and 69% of the eyes had an increase in height, whereas 20% of the eyes had a decrease in height. The variations in the dome height may result from the difference between the deepening of the peridome scleral excavation and the changes of the axial length.

Single-dose Effect of Intravitreal Dexamethasone Implant for Post-vitrectomy Macular Edema under Silicone Oil.

PURPOSE: To investigate the single-dose effect of intravitreal dexamethasone (DEX) implant for patients with post-vitrectomy macular edema (ME) under silicone oil (SO) tamponade. METHODS: Twelve eyes diagnosed with ME after undergoing pars plana vitrectomy with SO injections were retrospectively reviewed. Each eye received a single intravitreal DEX implant (0.7-mg, Ozurdex; Allergan Inc) injection as treatment for recalcitrant ME. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were recorded. RESULTS: Compared with baseline (1.24 ± 0.34), the mean LogMAR BCVA improved at 1 (1.14 ± 0.27), 3 (1.13 ± 0.22), and 6 (1.22 ± 0.30) months without statistical significance. Maximal CMT resolution was observed at 1 month after intravitreal injection. The CMT value improved significantly at 1 (P = .008), 3 (P = .006), and 6 (P = .009) months. IOP did not show significant elevation during follow-up. No serious adverse events were observed. CONCLUSION: Single-dose treatment of DEX implant may have benefit for recalcitrant post-vitrectomy ME under SO tamponade.

Peripheral Circumferential Retinal Detachment after Pars Plana Vitrectomy: Complications and Management.

PURPOSE: This study aimed to evaluate treatment outcomes and complications of peripheral circumferential retinal detachment (PCD) after successful vitrectomy. METHODS: Eyes diagnosed with PCD after pars plana vitrectomy (PPV) were retrospectively reviewed. The patient demographic data, complications, management, and treatment outcomes were collected and analyzed. RESULTS: The mean follow-up duration was 18.0 ± 11.9 months. BCVA ranged from light perception to 0.1 (median: counting fingers at 40 cm). Major complications included rubeosis iridis (seven eyes), vitreous hemorrhage (five eyes), hyphema (five eyes), corneal decompensation (three eyes), hypotony (two eyes), and neovascular glaucoma (two eyes). All eyes underwent peripheral retinectomy to remove the detached retina and release traction. Complete retinal reattachment was achieved in all eyes. The final BCVA ranged from hand motion to 0.1 (median: counting fingers at 30 cm). CONCLUSION: PCD may be associated with delayed-onset complications, causing severe loss of vision. Proper management, including peripheral retinectomy, may preserve visual function.

Early Intervention in Orbital Floor Fractures: Postoperative Ocular Motility and Diplopia Outcomes.

Purpose: Orbital floor fractures commonly occur during orbital trauma. Currently, the indications for orbital fracture repair and the appropriate duration between trauma and surgical intervention remain controversial. Methods: Eyes diagnosed with orbital floor fractures that underwent reconstruction surgery were retrospectively reviewed. Demographic data were analyzed. Patients were classified based on the timing of the surgical intervention after injury. Ocular limitation and diplopia were evaluated preoperatively and postoperatively at one week, one month, and three months. Results: Two hundred seventy eyes of 270 patients (174 males and 96 females, mean age: 40.9 ± 16.3 years) were identified. The mean duration from injury to surgical intervention was 18.0 ± 21.2 days (range: 0−117 days). In the subgroup analysis, compared to delayed treatment, the early repair of floor fractures, i.e., within 7 days, was associated with significant motility and diplopia resolution at one week (p = 0.001, p < 0.001), one month (p < 0.001, p < 0.001), and three months (p < 0.001, p < 0.001). Sex and the duration from injury to repair were significantly associated with postoperative ocular motility (p = 0.001; p = 0.024) and diplopia (p < 0.001; p = 0.008) at three months. Multivariate analysis revealed that preoperative limitation and diplopia were correlated with postoperative limitation (p = 0.007) and diplopia (p = 0.001), respectively. Conclusions: The duration between orbital floor fracture and surgical treatment was associated with postoperative limitation and diplopia. Our results suggest that earlier intervention in symptomatic patients with orbital trauma may improve postoperative visual function.

Baseline predictors for good visual gains after anti-vascular endothelial growth factor therapy for myopic choroidal neovascularization.

To investigate optical coherence tomography (OCT) and OCT angiography (OCTA) biomarkers for good visual outcomes in eyes with myopic choroidal neovascularization (mCNV) following anti-vascular endothelial growth factor (anti-VEGF) therapy. Patients diagnosed with mCNV via multimodal imaging were retrospectively reviewed. Baseline demographic data and biomarkers were collected. Anti-VEGF treatment based on a pro re nata (PRN) regimen was conducted on all eyes. The visual gains of ≥ 15 ETDRS letters or < 15 letters at 12-month were classified into two groups. Regression analysis was used to identify variables associated with significant best-corrected visual acuity (BCVA) improvement. Among 34 patients, 17 eyes and 17 eyes were classified into the two groups. There were no statistically significant differences in qualitative OCTA biomarkers between the two groups. The ≥ 15 letters group had significantly thicker subfoveal choroid thickness (SFCT) (79.97 ± 33.15 vs. 50.66 ± 18.31, P = 0.003), more ellipsoid zone integrity (58.8% vs. 23.5%, P = 0.037) and lower levels of fractal dimension (1.45 ± 0.101 vs. 1.53 ± 0.082, P = 0.031) than the < 15 letters group. SFCT and the ellipsoid zone integrity were correlated with 15 letters or more VA improvement in both univariable and multivariable analyses (P = 0.023 and P = 0.044, respectively). Thicker SFCT and integrity of the ellipsoid zone at baseline were associated with greater visual gains at 12 months. OCTA biomarkers seem to play a less important role in predicting the visual outcome of mCNV.

An Outperforming Artificial Intelligence Model to Identify Referable Blepharoptosis for General Practitioners.

The aim of this study is to develop an AI model that accurately identifies referable blepharoptosis automatically and to compare the AI model's performance to a group of non-ophthalmic physicians. In total, 1000 retrospective single-eye images from tertiary oculoplastic clinics were labeled by three oculoplastic surgeons as having either ptosis, including true and pseudoptosis, or a healthy eyelid. A convolutional neural network (CNN) was trained for binary classification. The same dataset was used in testing three non-ophthalmic physicians. The CNN model achieved a sensitivity of 92% and a specificity of 88%, compared with the non-ophthalmic physician group, which achieved a mean sensitivity of 72% and a mean specificity of 82.67%. The AI model showed better performance than the non-ophthalmic physician group in identifying referable blepharoptosis, including true and pseudoptosis, correctly. Therefore, artificial intelligence-aided tools have the potential to assist in the diagnosis and referral of blepharoptosis for general practitioners.

Ocular Decompression Retinopathy after Anterior Chamber Paracentesis for Neovascular Glaucoma.

Ocular decompression retinopathy (ODR) is a rare complication associated with intraocular pressure (IOP)-lowering interventions. We report a case of neovascular glaucoma in the left eye with marked IOP elevation (33 mmHg in the left eye). The IOP in the left eye did not improve despite medical treatment. Paracentesis of the left eye was then performed, and the IOP in the left eye decreased to 9 mmHg. One day after the procedure, several intraretinal hemorrhages, Roth spots, and subhyaloid hemorrhages appeared in the fundus of the left eye. Left eye retinopathy was likely ODR because of the rapid decline in IOP.

Combined quantitative and qualitative optical coherence tomography angiography biomarkers for predicting active neovascular age-related macular degeneration.

To investigate choroidal neovascularization (CNV) characteristics after anti-vascular endothelial growth factor (anti-VEGF) therapy in patients with neovascular age-related macular degeneration by optical coherence tomography angiography (OCTA) and to assess the potential predictive role of combined qualitative and quantitative biomarkers for disease activity. Patients diagnosed with type 1 or type 2 CNV via multimodal imaging who had received anti-VEGF treatment were retrospectively reviewed. Qualitative and quantitative CNV responses on OCTA after serial injections were analyzed. The enrolled eyes were divided into two groups based on treatment intervals during follow-up, including an active group with less than 12 weeks intervals and a stable group with 12 weeks or longer intervals. Fifty-six eyes of 56 patients were included in the study. Twenty-seven eyes (48.2%) were classified as the "active group", and 29 eyes (51.8%) were categorized as the "silent group". Qualitative biomarkers of CNV showed significant differences between the two groups (branching capillaries: 48.1% vs 6.9%, p = 0.001; anastomoses and loops: 81.5% vs 13.8%, p < 0.001; peripheral arcade: 40.7% vs 10.3%, p = 0.013, and hypointense halo: 81.5% vs 41.4%, p = 0.002). A significantly higher vessel density was found in the active group (median 39.6% vs 30.5%, p = 0.003). "Anastomoses and loops" and "vessel density" predicted an active CNV status with a probability of 93.7% and achieved the best performance. The combination of two potential biomarkers of CNV on OCTA shows good discrimination for the prediction of recurrent exudation auxiliary to structural OCT that might associate with disease activity.

A deep learning approach to identify blepharoptosis by convolutional neural networks.

PURPOSE: Blepharoptosis is a known cause of reversible vision loss. Accurate assessment can be difficult, especially amongst non-specialists. Existing automated techniques disrupt clinical workflow by requiring user input, or placement of reference markers. Neural networks are known to be effective in image classification tasks. We aim to develop an algorithm that can accurately identify blepharoptosis from a clinical photo. METHODS: A total of 500 clinical photographs from patients with and without blepharoptosis were sourced from a tertiary ophthalmic center in Taiwan. Images were labeled by two oculoplastic surgeons, with an independent third oculoplastic surgeon to adjudicate disagreements. These images were used to train a series of convolutional neural networks (CNNs) to ascertain the best CNN architecture for this particular task. RESULTS: Of the models that trained on the dataset, most were able to identify ptosis images with reasonable accuracy. We found the best performing model to use the DenseNet121 architecture without pre-training which achieved a sensitivity of 90.1 % with a specificity of 82.4 %, compared to the worst performing model which was used a Resnet34 architecture with pre-training, achieving a sensitivity of 74.1 %, and specificity of 63.6 %. Models with and without pre-training performed similarly (mean accuracy 82.6 % vs. 85.8 % respectively, p = 0.06), though models with pre-training took less time to train (1-minute vs. 16 min, p < 0.01). CONCLUSIONS: We report the use of AI to accurately diagnose blepharoptosis from a clinical photograph with no external reference markers or user input requirement. Most current-generation CNN architectures performed reasonably on this task, with the DenseNet121, and Resnet18 architectures without pre-training performing best in our dataset.

Orbital and ocular adnexal lymphoma: a review of epidemiology and prognostic factors in Taiwan.

PURPOSE: To investigate the clinical features, prognostic outcomes of patients with orbital and ocular adnexal lymphoma (OALs) in Taiwanese cohort. METHODS: Total 112 patients with OALs were retrospectively reviewed. Demographic information such as age, gender, lymphoma subtype, tumor location and treatment modalities were recorded. The primary endpoints were disease-specific survival (DSS), and progression-free survival (PFS). RESULTS: The mean patient age was 59.0 ± 15.5 years (range, 23-92 years). The major histopathologic subtypes were mucosa-associated lymphoid tissue (MALT) lymphoma in 76 patients (67.9%), followed by diffuse large B-cell lymphoma (DLBCL) (9.8%), follicular cell lymphoma (FL) (8.0%), and small lymphocytic lymphoma (SLL) (5.4%). The anatomical locations for OALs were the orbit (44 patients, 39.3%), the conjunctiva (31 patients, 27.7%), the lacrimal gland (28 patients, 25.0%), and the eyelid (8 patients, 7.1%). With a mean follow-up time of 74.5 ± 59.8 months (range 6-342 months), the DSS for all patients were 93.1%, 87.7%, and 68.8% at 60, 120, and 180 months' follow-up, respectively. The PFS at 60, 120, and 180 months' follow-up were 86.2%, 61.2%, and 44.6%, respectively. Regarding the analysis of prognostic factors, patients with high grade lymphoma subtype and advanced stage exhibited a worse prognosis. CONCLUSIONS: MALT type lymphoma constitutes most of OALs in Taiwan and occurs more frequently than in Western countries. Patients with MALT lymphoma, FL, SLL and earlier stage have favorable outcomes compared with patients of high grade lymphoma and Ann Arbor stage IV lymphoma.

A Highly Selective Rho-Kinase Inhibitor (ITRI-E-212) Potentially Treats Glaucoma Upon Topical Administration With Low Incidence of Ocular Hyperemia.

Purpose: The purpose of this study was to investigate the IOP-lowering effects of the ITRI-E-212, a new Rho-associated protein kinase (ROCK) inhibitor. ITRI-E-212 improved fluid outflow through the trabecular meshwork and reduced IOP with transient and mild conjunctival hyperemia. ITRI-E-212 can potentially be developed into new antiglaucoma agents. Methods: ITRI-E-212 was selected from more than 200 amino-isoquinoline structures because of its adequate solubility and drug-loading percentage in eye drops. ITRI-E-212 has less than 50% inhibitory concentration (IC50) against ROCK2. The in vitro kinase inhibition was evaluated using the ADP-Glo kinase assay. A comprehensive analysis of the kinase inhibitor selectivity of ITRI-E-212 was performed using the KINOMEscan methodology. The IOP-lowering effect and tolerability of ITRI-E-212 were investigated in normotensive and ocular hypertensive rabbits. The pharmacokinetics study was performed in vivo in the aqueous humor (AH), and hyperemia was assessed. Results: ITRI-E-212 showed high in vitro inhibitory activity against ROCK2 and high specificity against AGC kinases. The mean IOP-lowering effect of ITRI-E-212 in normotensive and ocular hypertensive models was 24.9% and 28.6%, respectively; 1% ITRI-E-212 produced notable reductions in IOP that were sustained for at least 6 hours after each dose once per day. Only transient, mild hyperemia was observed. The compound extracted from the AH reached 78.4% ROCK2 kinase inhibition at 1 hour after dose administration and was sustained for 4 hours. Conclusions: ITRI-E-212 is a novel and highly specific ROCK2 inhibitor with the ability to lower IOP in animal models. It has favorable pharmacokinetic and ocular tolerability profiles with only minimal conjunctival hyperemia.

Protective effects of hypercapnic acidosis on Ischemia-reperfusion-induced retinal injury.

Ischemia-reperfusion (I/R) injury is associated with numerous retinal diseases, such as diabetic retinopathy, acute glaucoma, and other vascular retinopathies. Hypercapnic acidosis (HCA) has a protective effect on lung, myocardial, and central nervous system ischemic injury models. However, no study has evaluated its protective effects in an experimental retinal I/R injury model. In this study, retinal I/R injury was induced in Sprague Dawley rats by elevating the intraocular pressure to 110 mmHg for 60 minutes. HCA was induced before and after the injury. After 24 hours, the terminal dUTP nick end labeling assay was performed. Moreover, the ratios of cleaved caspase-3/total caspase-3, phosphorylated IκB/IκB, and phosphorylated p38 were measured through Western blotting. After 7 days, the rats' aqueous humor was analyzed. In addition, electroretinography and retinal thickness measurement were performed in the rats. Moreover, the retinal neural cell line RGC-5 was exposed to 500 µM H2O2 for 24 hours to induce a sustained oxidative stress in vitro. The effects of HCA were evaluated by comparing oxidative stress, MAPK signals, NF-κB signals, survival rates, and apoptosis rates in the RGC-5 cells before and after H2O2 exposure. We further investigated whether the potent I/R-protective heat shock protein (HSP) 32 contribute to protective effects of HCA. Our results indicated that HCA has protective effects against retinal I/R injury both in vivo and in vitro, at multiple levels, including antiapoptotic, anti-inflammatory, antioxidative, and functional retinal cell protection. Further research clarifying the role of HCA in retinal I/R injury prevention and treatment is warranted.

A cluster of nontuberculous mycobacterial endophthalmitis (NTME) cases after cataract surgery: clinical features and treatment outcomes.

PURPOSE: To report the clinical features and treatment outcomes in a cluster of patients with endophthalmitis after cataract surgery caused by nontuberculous mycobacterium. PATIENTS AND METHODS: Retrospective chart review and noncomparative, consecutive case series. Nine consecutive cases of endophthalmitis, after cataract surgery in a local clinic, were referred to our hospital. The treatment outcomes and analysis of risk factors for infection are reported. RESULTS: The major symptoms at presentation were pain, redness, and decreased vision. Best-corrected visual acuity at presentation ranged from hand motion in two cases (22%), counting fingers at 30 cm in three cases (33%), 20/100 in two cases (20%), 20/63 in one case (11%), to 20/50 in one (11%) case. The mean duration between cataract surgery to presentation at our hospital was 16.7 days. Prompt intravitreal injections (IVI) of amikacin (0.4 mg/0.1 mL) and vancomycin (1 mg/0.1 mL), with topical moxifloxacin were administered initially. Pars plana vitrectomy with amikacin (10 mg/L) and vancomycin (20 mg/L) intravitreal irrigation, and intraocular lens removal were performed for all patients. Systemic antibiotics including amikacin and tigecycline were prescribed for 10 days, and clarithromycin was prescribed for at least 3 months. In all the nine cases, the culture results from either aqueous tapping or vitrectomy sample were positive for nontuberculous Mycobacterium: Mycobacterium abscessus/chelonae, which was compatible with iatrogenic clustered infection. At the last follow-up, three cases (33.3%) had best-corrected visual acuity of counting fingers at 30 cm, while the other six cases had no light perception. Two cases (22%) were enucleated and one case (11%) had phthisis bulbi. CONCLUSION: Nontuberculous mycobacterium endophthalmitis (NTME) often induces chronic recurrent or persistent intraocular inflammation. Very poor outcomes despite aggressive antibiotic treatment and repeated surgical interventions are suggestive of the virulent nature of the organisms. Autoclave sterilization and perioperative disinfection may help in reducing iatrogenic clustered infection.

Combined trabeculotomy-trabeculectomy using the modified Safer Surgery System augmented with MMC: its long-term outcomes of glaucoma treatment in Asian children.

BACKGROUND: This study aimed to study the long-term surgical outcomes of combined trabeculotomy-trabeculectomy (CTT) using the modified Safer Surgery System in treating childhood glaucoma at a tertiary medical center in Taiwan. METHODS: Retrospective, consecutive, noncomparative case series. We retrospectively reviewed medical records of 42 pediatric patients (age 0-18 years) who had CTT performed on their 65 eyes using the modified Safer Surgery System. The study period spanned 18 years (from January 1, 1997, to December 31, 2014). We evaluated the outcome in terms of postoperative intraocular pressure (IOP), axial length growth, disc cupping reversal, and use of antiglaucoma medications. The surgical success was rated using the Kaplan-Meier survival analysis and based on the incidence of complications. RESULTS: The mean follow-up period was 85.05 ± 32.17 months (range 14-200). After operation, IOP dropped significantly from 35.76 ± 9.44 mmHg (mean ± SD) to 16.18 ± 7.20 mmHg together with a significant reversal of optic disc cupping. Similarly, the use of antiglaucoma medications was also significantly reduced in number from 1.26 ± 0.50 to 0.43 ± 0.70. Most of the axial lengths of the eyes measured at the last follow-up visit showed growths within the average ± 2 SDs in comparison with the healthy, age-matched population. After surgery, the qualified success rate was 90.77% at the end of the first year, 90.77% at the second year, 87.64% at the fifth year, 84.51% at the 10th year, and 81.38% at the 15th year. No serious intraoperative or postoperative complications were found. CONCLUSIONS: For Taiwanese children, the combined trabeculotomy-trabeculectomy using the modified Safer Surgery System offered an efficient and safe surgical option for treating glaucoma with long-term satisfactory control of IOP.

Sumatriptan-induced angle-closure glaucoma: A case report.

RATIONALE: Drug-induced bilateral angle-closure glaucoma is a rare event and should be treated correctly and promptly to prevent visual loss. PATIENT CONCERNS: We report a rare case of sumatriptan-induced bilateral angle-closure glaucoma in a young woman with migraine, and explore the possible mechanism. DIAGNOSES: We describe the clinical outcome of a patient with sumatriptan-induced bilateral angle-closure glaucoma. The patient presented with bilateral acute elevation of intraocular pressure (IOP) and myopic shift. INTERVENTIONS: The clinical symptoms and signs resolved rapidly after treatment with a topical cycloplegic agent, topical steroid, and aqueous suppressant. OUTCOMES: Based on the suspicious of malignant glaucoma, we prescribed topical phenylephrine, whose application immediately lowered the IOP. All symptoms resolved after treatment with a long-acting cycloplegic agent, topical steroid, and aqueous suppressant for 3 days. LESSONS: We presume that the mechanism underlying sumatriptan-induced bilateral angle-closure glaucoma may be correlated to the malignant glaucoma. Timely diagnosis and appropriate treatment are essential for resolving this ophthalmic emergency.

Rapid onset of radiation maculopathy after whole-brain radiation therapy: A case report.

BACKGROUND: Radiation maculopathy is a phenomenon that occurs after radiation exposure. The rapid onset of unilateral macular atrophy without peripheral retinopathy after radiation has rarely been described. METHODS: A case report and literature review. RESULTS: We report a case of stage 4 non-small cell lung cancer under targeted therapy using Gefitinib who presented with severely impaired visual acuity related to rapid onset of unilateral macular atrophy and diminished photoreceptor inner segment/outer segment (IS/OS) junction 1 month after whole-brain radiation therapy. The fundus fluorescein angiography revealed an enlarged diamond-shaped clear-cut foveal avascular zone in the macula without peripheral retinal vascular changes that differed from typical radiation retinopathy. We confirmed the diagnosis by evaluating the total radiation dosage and by excluding target therapy-induced maculopathy based on a review of the medical literature. CONCLUSION: Current therapeutic interventions for macular atrophy after radiation therapy remain a challenge. Vasodilators or antiplatelet medication may be beneficial; however, long-term follow-up is needed. Further studies are required to support the use of early aggressive therapy for the prevention of radiation retinopathy.

Combined vitamin C sonophoresis and neodymium-doped yttrium aluminum garnet (NdYAG) laser for facial hyperpigmentation: An outcome observation study in Asian patients.

BACKGROUND: The neodymium-doped yttrium aluminum garnet (NdYAG) laser therapy has been a popular technique for facial rejuvenation but certain adverse effects like post-inflammatory hyperpigmentation are issues of concern to Asian patients. AIMS: To assess the outcome following combined treatment with vitamin C sonophoresis and NdYAG laser, in selected cases of facial hyperpigmentation. METHODS: Twenty three women with dyschromia or melasma who had undergone five sessions of Q-switched NdYAG laser therapy followed by transdermal delivery of vitamin C via sonophoresis were selected after a retrospective review of case records. The objective and subjective clinical outcomes and the side effects, including erythema, scaling, pruritus, dryness and post-inflammatory hyperpigmentation were evaluated. RESULTS: In both objective or subjective outcomes, 91.3% (21/23) of the patients showed an excellent or better outcome, while 8.7% (2/23) showed no change. A majority of the patients (73.9%, 17/23) experienced no post-inflammatory hyperpigmentation or had slight post-inflammatory hyperpigmentation which quickly resolved within 1 week. Only one (4.3%) patient had extreme post-inflammatory hyperpigmentation which lasted for over a month. LIMITATIONS: This was a retrospective study without a control group; a comparative study with a control group (patients treated with the laser alone, without vitamin C sonopheresis) is needed to determine the difference in the outcome. CONCLUSION: The use of vitamin C sonophoresis along with NdYAG laser may reduce the incidence of adverse effects in Asian patients. Patients experienced obvious improvement in hyperpigmentation and had lower chances of experiencing extreme or severe post-inflammatory hyperpigmentation.

Organization of wound healing services: The impact on lowering the diabetes foot amputation rate in a ten-year review and the importance of early debridement.

Diabetes foot ulceration (DFU) has a negative impact on the quality of life and leads to disabling morbidity, such as lower extremity amputation (LEA). This study aimed to evaluate the LEA trend before and after the establishment of the diabetes foot team, an on-time debridement, on-site screening, and multidisciplinary integration with standardizing care, in Chang Gung Memorial Hospital, Chia Yi, Taiwan, starting in 2010. The study retrospectively investigated the non-traumatic LEA rate in diabetes foot (identified by using ICD-9-Clinical Modification (CM) codes, 250.70-250.83) and whole patients with diabetes (ICD-9 250.XX) yearly from 2004 to 2013. Patients were enrolled from hospitalization, emergency room (ER), or outpatient departments, respectively. Despite the overall incidence of diabetes foot in patients with diabetes remaining constant, from 3.47% in 2004 to 3.58% in 2013, the incidence of hospitalized diabetes foot from diabetes reduced, from 2.83% in 2004 to 1.51% in 2013. Introduction of integrated wound care also led to a reduction of the average LEA rate in hospitalized patients, from 15.27% (2004-2009) to 6.08% (2010-2013) (P<0.001). A similar decline of the LEA rate was observed for patients from hospitalization, ER and outpatient departments together with an average LEA rate from 7.99% (2004-2009) down to 3.02% (2010-2013) (P<0.001). In trend analysis, the curve estimation revealed a quadratic trend in the relationship between LEA rate and time (R-square=0.869, P=0.001) for hospitalized patients as well as a linear (R-square=0.819, P<0.001) and quadratic (R-square=0.845, P=0.001) trend in the relationship between LEA rate and time for hospitalization, ER, and outpatient departments together. The LEA rate for DM patients declined from 372.72/100,000 in 2004 to 61.74/100,000 in 2013. With establishment of an organizing, standardized wound care protocol and integrated multidisciplinary team, we demonstrated a significant decline in the LEA rate both in diabetes foot patients and all patients with diabetes. These improvements can be attributed to introducing an efficient pathway with on-time debridement and early intervention of diabetes foot ulcers.

Glycemic variability and diabetes retinopathy: a missing link.

Daily glucose variability, such as fasting plasma glucose fluctuation or postprandial hyperglycemia, has been proposed as contributors to diabetes-related macrovascular complications. However, its impacts on microvascular complications, such as diabetes retinopathy remain controversial. We reviewed the current evidence of the relationship between glycemic variability and diabetes retinopathy in patients with type 1 or type 2 diabetes. In general, the short-term glycemic fluctuation, either expressed as standard deviation of fasting glucose or mean glucose levels, may contribute to the development or progression of diabetic retinopathy in patients with type 2 diabetes, whereas long-term glycemic fluctuation, reflected by variation of levels of HbA1c, appeared to show a stronger association with diabetes retinopathy both in patients with type 1 and type 2 diabetes. These findings emphasize the need to reduce glycemic variability by various measures in order to reduce development and progression of diabetes retinopathy both in type 1 and type 2 diabetes patients.