Sympathetic ophthalmia: epidemiology and cohort-based assessment of clinical outcomes.

BACKGROUND: The purpose of this study was to report the incidence, time after inciting event, aetiology and risk after specific intraocular procedures and the visual outcomes associated with sympathetic ophthalmia (SO) occurrence. METHODS: This study reports data from multiple retrospective cohorts: retrospective population-based data were extracted from the TRICARE service network (between 2017 and 2021) and retrospective case-based data from the Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) database (cohorts from the UK, South India and North India). RESULTS: There were 159 patients with SO identified. The length of time from sensitising event to SO occurrence was a median of 151 days (range: 6-9100 days).In the TRICARE database, 2 patients developed SO after open globe trauma and primary repair (of 615 eyes, rate 0.33%; 95% CI 1.26% to 1.30%). None developed SO after vitrectomy (total of 23 903 events; 95% CI 0% to 0.012%). The combined North Indian and UK cohorts reported 78.6% (81 patients) after trauma, 18.45% (19 patients) after elective surgery.Visual outcomes were reported in the OASIS database for 98.01% of patients (155 of 157 patients). The median presenting and final best corrected visual acuity (BCVA) for the inciting eye were no perception of light, the median presenting and final BCVA for the sympathising eye were 0.65 and 0.3 logMAR, respectively. CONCLUSION: This study identified 159 cases of SO. With poor visual outcomes in the inciting eye, early diagnosis and management are crucial for optimising visual outcomes in the sympathising eye.

Epidemiology of Intermediate Uveitis.

Intermediate uveitis is defined as inflammation of the vitreous and pars planitis. Etiology can be infectious, associated with a systemic disease, neoplastic or idiopathic. Pars planitis is the term used for idiopathic intermediate uveitis that presents with snowballs and snowbanks. While relatively rare, intermediate uveitis is present globally and typically affects adult females. Awareness of the presentation and a dilated fundus examination in patients presenting with floaters is essential to the diagnosis. PCR testing has enhanced the ability to diagnose infectious and neoplastic conditions that masquerade as intermediate uveitis. A structured review of systems and focused imaging, and laboratory testing will assist with early diagnosis and initiation of treatment.

Temporary keratoprosthesis and primary corneal graft for ocular trauma: a systematic review and meta-analysis.

PURPOSE: When severe retinal and corneal injury occur together, a temporary keratoprosthesis (TKP) is often a last resort to allow posterior segment visualization to enable vitreoretinal surgery, followed by a penetrating keratoplasty (PKP) which can restore corneal clarity in a single operation. We aimed to assess visual outcomes following combined PKP and vitreoretinal surgery with the use of a TKP for cases of ocular trauma. DESIGN: A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: CRD42023423518). METHODS: CENTRAL, MEDLINE, Embase, ISRCTN registry and ClinicalTrials.gov were searched from inception to 27 April 2023. Randomized and non-randomized studies assessing visual outcomes after combined vitreoretinal surgery and PKP with the use of a TKP after ocular trauma were eligible for inclusion. Outcomes included change in best corrected visual acuity, corneal graft survival and retinal reattachment at final follow up. Proportional meta-analysis was used to estimate the overall rate of the primary outcomes. Risk of bias for non-randomized studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. RESULTS: A total of 19 studies met inclusion criteria reporting a total of 352 eyes. All studies were retrospective and non-randomized with follow up times ranging from 6 to 91 months, with at least 79% of outcomes reported after 6 months. After combined surgery the rate of corneal graft survival was 52% (95% CI 0.41-0.62; I2 60%) successful retinal attachment was 79% (95% CI 0.73-0.84; I2 0%). and improved visual acuity, when compared to no change or decrease in visual acuity, was 45% (95% CI 0.32-0.59; I2 66%). CONCLUSION: Patients with severe injury affecting the anterior and posterior segments have very limited treatment options. This systematic review found that when combined vitreoretinal surgery and PKP with a TKP are performed, approximately half of corneal grafts survive, anatomically successful retinal reattachment is likely, and a similar proportion of patients benefit in terms of improved visual acuity, compared to their preoperative function. This systematic review of the available literature may help inform surgeons of the benefits of using a TKP for cases of ocular trauma.

Traumatic retinal detachment: A contemporary update.

Retinal detachment following ocular trauma (TrRD) is one of the leading causes of blindness and visual impairment worldwide. In the absence of a standardized definition, the diagnosis of traumatic retinal detachment relies on identifying a history of trauma that precedes the detachment. There is an increasing pool of data regarding the etiology and epidemiology of TrRD.Various causes of TrRD mentioned in the literature include work-related eye trauma in construction and manufacturing industries, sports injuries, explosive eye injuries, road traffic accidents, and intraocular foreign bodies. Although there is extensive literature on post-trauma retinal detachments, a comprehensive discussion of its pathogenesis, management, outcomes, and complications is lacking. We offer an in-depth review of the epidemiology, risk factors, pathogenesis, diagnosis, management, and outcomes of TrRD based on the current literature.

Diagnostic work-up of retinal vasculitis: An algorithmic approach.

Retinal vasculitis has heterogenous etiologies encompassing infections, autoimmune, masquerades and idiopathic. The heterogeneity in the underlying clinical features and aetiologies of retinal vasculitis makes its diagnosis challenging for clinicians and the work up thus becomes quite extensive and many a times several unwarranted investigations are done to look for a possible etiology. Timely and accurate diagnosis is crucial for effective management and vision preservation. The algorithmic approach needs understanding of the phenotype, clinical as well as imaging biomarkers so that only customized investigations are done in order to make the timely diagnosis and initiate specific therapy wherever required. In this review article, we shall present an algorithmic approach that combines clinical assessment, ophthalmic imaging, laboratory investigations, and targeted ancillary tests.

Early versus Delayed Timing of Primary Repair after Open-Globe Injury: A Systematic Review and Meta-analysis.

TOPIC: The timing of primary repair of open-globe injury is variable in major trauma centers worldwide, and consensus on optimal timing is lacking. CLINICAL RELEVANCE: Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimize the risk of potentially blinding complications such as endophthalmitis, thereby optimizing visual outcomes. METHODS: A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (International Prospective Register of Systematic Reviews identifier, CRD42023442972). The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ISRCTN registries and ClinicalTrials.gov were searched from inception through October 29, 2023. Prospective and retrospective nonrandomized studies of patients with open-globe injury with a minimum of 1 month of follow-up after primary repair were included. Primary outcomes included visual acuity at last follow-up and the proportion of patients with endophthalmitis. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Fifteen studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with 0.30 odds of endophthalmitis compared with primary repair conducted more than 24 hours after trauma (odds ratio, 0.39; 95% confidence interval [CI], 0.19-0.79; I2 = 95%; P = 0.01). No significant difference was found in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared with less than, 24 hours after trauma (odds ratio, 0.89; 95% CI, 0.61-1.29; I2 = 70%; P = 0.52). All included studies were retrospective and nonrandomized, demonstrating an overall low certainty of evidence on GRADE assessment. DISCUSSION: Only retrospective data exist around the effect of timing of open-globe repair, resulting in low certainty of the available evidence. However, this review of current evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury is associated with a reduced endophthalmitis rate compared with longer delays, consistent with delay to primary repair increasing endophthalmitis risk. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A serum B-lymphocyte activation signature is a key distinguishing feature of the immune response in sarcoidosis compared to tuberculosis.

Sarcoidosis and tuberculosis (TB) are two granulomatous diseases that often share overlapping clinical features, including uveitis. We measured 368 inflammation-related proteins in serum in both diseases, with and without uveitis from two distinct geographically separated cohorts: sarcoidosis from the Netherlands and TB from Indonesia. A total of 192 and 102 differentially expressed proteins were found in sarcoidosis and active pulmonary TB compared to their geographical healthy controls, respectively. While substantial overlap exists in the immune-related pathways involved in both diseases, activation of B cell activating factor (BAFF) signaling and proliferation-inducing ligand (APRIL) mediated signaling pathways was specifically associated with sarcoidosis. We identified a B-lymphocyte activation signature consisting of BAFF, TNFRSF13B/TACI, TRAF2, IKBKG, MAPK9, NFATC1, and DAPP1 that was associated with sarcoidosis, regardless of the presence of uveitis. In summary, a difference in B-lymphocyte activation is a key discriminative immunological feature between sarcoidosis/ocular sarcoidosis (OS) and TB/ocular TB (OTB).

Double Kissing Mini-Culotte Stenting in Unprotected Distal Left Main Bifurcation Under Optical Coherence Tomography Guidance: Immediate and Short-Term Outcomes.

Culotte stenting is an effective strategy for left main coronary artery bifurcation lesions. Increased side branch ostial restenosis is the main drawback of culotte stenting. This is due to a napkin ring or potential gap produced at the ostium of the side branch. A bench study by Toth et al11 has shown that additional sequential kissing balloon dilation before main vessel stenting can prevent this deformity. We report immediate and short-term results of double kissing (DK) mini-culotte stenting with a 1-year angiographic follow-up. Between March 2020 and December 2022, 45 patients with distal left main (LM) disease underwent DK mini-culotte stenting at our center under optical coherence tomography guidance. Of 45 patients (male: 35 (77.77%); mean age: 63.67 ± 4.94 years), chronic coronary artery syndrome was present in 26 (57.8%) and unstable angina in the remainder. All lesions were Medina (1,1,1), (0,1,1), or (1,0,1), with a median Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score of 28 (interquartile range 23 to 29). All procedures were technically successful with no adverse clinical events (death, myocardial infarction, or stent thrombosis). Under optical coherence tomography guidance, adequate minimal stent area of 13.28 ± 0.77 mm2, 8.25 ± 0.29 mm2, and 7.54 ± 0.45 mm2 was achieved in LM, left anterior descending, and left circumflex, respectively. Adequate stent expansion of >80% was achieved in all cases. At the end of 1 year, the incidence of major adverse cardiovascular events was 2.2%. Furthermore, restenosis of the side branch developed in 1 patient (2.2%), which was managed conservatively. DK mini-culotte stenting in the distal LM bifurcation has shown promising results and is effective in preventing side branch stent deformation and its sequelae of in-stent restenosis.

Managing a patient with uveitis in the era of artificial intelligence: Current approaches, emerging trends, and future perspectives.

The integration of artificial intelligence (AI) with healthcare has opened new avenues for diagnosing, treating, and managing medical conditions with remarkable precision. Uveitis, a diverse group of rare eye conditions characterized by inflammation of the uveal tract, exemplifies the complexities in ophthalmology due to its varied causes, clinical presentations, and responses to treatments. Uveitis, if not managed promptly and effectively, can lead to significant visual impairment. However, its management requires specialized knowledge, which is often lacking, particularly in regions with limited access to health services. AI's capabilities in pattern recognition, data analysis, and predictive modelling offer significant potential to revolutionize uveitis management. AI can classify disease etiologies, analyze multimodal imaging data, predict outcomes, and identify new therapeutic targets. However, transforming these AI models into clinical applications and meeting patient expectations involves overcoming challenges like acquiring extensive, annotated datasets, ensuring algorithmic transparency, and validating these models in real-world settings. This review delves into the complexities of uveitis and the current AI landscape, discussing the development, opportunities, and challenges of AI from theoretical models to bedside application. It also examines the epidemiology of uveitis, the global shortage of uveitis specialists, and the disease's socioeconomic impacts, underlining the critical need for AI-driven approaches. Furthermore, it explores the integration of AI in diagnostic imaging and future directions in ophthalmology, aiming to highlight emerging trends that could transform management of a patient with uveitis and suggesting collaborative efforts to enhance AI applications in clinical practice.

Natural Language Processing in medicine and ophthalmology: A review for the 21st-century clinician.

Natural Language Processing (NLP) is a subfield of artificial intelligence that focuses on the interaction between computers and human language, enabling computers to understand, generate, and derive meaning from human language. NLP's potential applications in the medical field are extensive and vary from extracting data from Electronic Health Records -one of its most well-known and frequently exploited uses- to investigating relationships among genetics, biomarkers, drugs, and diseases for the proposal of new medications. NLP can be useful for clinical decision support, patient monitoring, or medical image analysis. Despite its vast potential, the real-world application of NLP is still limited due to various challenges and constraints, meaning that its evolution predominantly continues within the research domain. However, with the increasingly widespread use of NLP, particularly with the availability of large language models, such as ChatGPT, it is crucial for medical professionals to be aware of the status, uses, and limitations of these technologies.

Beyond Pathology- Exploring Salutogenesis as a Novel Approach to Eye Inflammatory Disease Prevention and Management: A Perspective.

The aim of this perspective is to promote the theory of salutogenesis as a novel approach to addressing ophthalmologic inflammatory conditions, illustrating several concepts in which it is based upon and how they can be applied to medical practice. This theory can better contextualize why patients with similar demographics and exposures are not uniform in their clinical presentations. Stressors in daily life can contribute to a state of ill-health and there are various factors that help alleviate their negative impact. These alleviating factors are significantly impaired in people with poor vision, one of the most common presentations of ophthalmologic conditions. Salutogenic principles can guide the treatment of eye conditions to be more respectful of patient autonomy amidst shifting expectations of the doctor-patient relationship. Being able to take ownership of their health and feeling that their cultural beliefs were considered improves compliance and subsequently gives more optimal outcomes. Population-level policy interventions could also utilize salutogenic principles to identify previously overlooked domains that can be addressed. We identified several papers about salutogenesis in an ophthalmological context and acknowledged the relatively few studies on this topic at present and offer directions in which we can explore further in subsequent studies.

Clinical Insights: Antimicrobial Therapy for Infectious Uveitis.

Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.

Clinical Features and Predictors of Treatment Outcome in Patients with Ocular Tuberculosis from the Netherlands and Indonesia: The OculaR TB in Low versus High Endemic Countries (ORTEC) Study.

PURPOSE: To describe and compare clinical features, treatment approaches, and treatment outcomes of ocular tuberculosis (OTB) patients in the Netherlands, a low tuberculosis (TB)-endemic country, and Indonesia, a high TB-endemic country. We also aimed to identify predictors of treatment outcomes. METHODS: A medical chart review of 339 OTB patients (n = 93 from the Netherlands and n = 246 from Indonesia) was performed. The primary outcome was response to treatment, whether with or without anti-tubercular treatment, after six months of treatment initiation (good versus poor responders). RESULTS: Indonesian OTB patients displayed a higher prevalence of chest radiograph findings indicative of TB infection (p < 0.001) and concurrent active systemic TB (p = 0.011). Indonesian cohort exhibited a more acute and severe disease profile, including uveitis duration ≤ 3 months (p < 0.001), blindness (p < 0.001), anterior chamber (AC) cells ≥ 2+ (p < 0.001), and posterior synechiae (p < 0.001). Overall proportions of good responders to treatment were 67.6% in the Netherlands and 71.5% in Indonesia. Presence of AC cell ≥ 2+ (adjusted odds ratio (aOR): 2.12, 95% CI: 1.09-4.14), choroidal lesions other than serpiginous-like choroiditis (SLC) or tuberculoma (aOR: 4.47, 95% CI: 1.18-16.90), and retinal vasculitis (aOR: 2.32, 95% CI: 1.10-4.90) at baseline were predictors for poor response to treatment. CONCLUSIONS: Despite a more severe initial clinical presentation in the Indonesian cohort, the overall treatment outcomes of OTB was comparable in both cohorts. Three baseline clinical features were identified as predictors of treatment outcomes.

Evaluation of Patient Experiences with PocDoc, a Web-Based Eye Screening Tool.

INTRODUCTION: The efficacy of diagnostic and monitoring tools in ophthalmology is significantly influenced by patient engagement levels. This presents a notable challenge, especially in the context of developing tools designed for telemedicine applications. Ensuring consistent patient engagement is therefore crucial for the accurate and reliable utilization of these technologies. This study assesses patient perceptions and experiences after using a purpose-built web application, called PocDoc. METHODS: A cross-sectional questionnaire-based survey was conducted among 440 patients recruited from general and specialist eye clinics between March 2022 and October 2023, both before and after using the PocDoc app. RESULTS: Pre-test findings revealed that 86.8% of patients thought that a remote eye monitoring application would have use, while 70.9% anticipated frequent usage. Only 16.4% found it overly complex, and 55.2% perceived it as easy to use. Additionally, 34.5% foresaw the need for technical support, while 72.5% believed they would quickly grasp its use. In the post-test questionnaire, 63.3% of patients still expressed intent for frequent PocDoc usage. The perception of complexity decreased to 20.4%, with 79.3% finding it easy to use. The belief in the need for technical support decreased to 36.5%, while 89.9% felt confident in mastering the application quickly. Moreover, 77.3% found the application's functions well-integrated, and 64.6% were very confident using PocDoc. CONCLUSIONS: Results suggest patient receptivity to web-based applications, confirming their viability for specific patient groups. Overall, our study contributes to the growing body of evidence indicating that greater exposure to digital health tools can significantly influence patient acceptance and perceived ease of use, an insight that has important implications for the implementation and design of these technologies in clinical settings.

Optical coherence tomography choroidal enhancement using generative deep learning.

Spectral-domain optical coherence tomography (SDOCT) is the gold standard of imaging the eye in clinics. Penetration depth with such devices is, however, limited and visualization of the choroid, which is essential for diagnosing chorioretinal disease, remains limited. Whereas swept-source OCT (SSOCT) devices allow for visualization of the choroid these instruments are expensive and availability in praxis is limited. We present an artificial intelligence (AI)-based solution to enhance the visualization of the choroid in OCT scans and allow for quantitative measurements of choroidal metrics using generative deep learning (DL). Synthetically enhanced SDOCT B-scans with improved choroidal visibility were generated, leveraging matching images to learn deep anatomical features during the training. Using a single-center tertiary eye care institution cohort comprising a total of 362 SDOCT-SSOCT paired subjects, we trained our model with 150,784 images from 410 healthy, 192 glaucoma, and 133 diabetic retinopathy eyes. An independent external test dataset of 37,376 images from 146 eyes was deployed to assess the authenticity and quality of the synthetically enhanced SDOCT images. Experts' ability to differentiate real versus synthetic images was poor (47.5% accuracy). Measurements of choroidal thickness, area, volume, and vascularity index, from the reference SSOCT and synthetically enhanced SDOCT, showed high Pearson's correlations of 0.97 [95% CI: 0.96-0.98], 0.97 [0.95-0.98], 0.95 [0.92-0.98], and 0.87 [0.83-0.91], with intra-class correlation values of 0.99 [0.98-0.99], 0.98 [0.98-0.99], and 0.95 [0.96-0.98], 0.93 [0.91-0.95], respectively. Thus, our DL generative model successfully generated realistic enhanced SDOCT data that is indistinguishable from SSOCT images providing improved visualization of the choroid. This technology enabled accurate measurements of choroidal metrics previously limited by the imaging depth constraints of SDOCT. The findings open new possibilities for utilizing affordable SDOCT devices in studying the choroid in both healthy and pathological conditions.

Evaluating the OpenAI's GPT-3.5 Turbo's performance in extracting information from scientific articles on diabetic retinopathy.

We aimed to compare the concordance of information extracted and the time taken between a large language model (OpenAI's GPT-3.5 Turbo via API) against conventional human extraction methods in retrieving information from scientific articles on diabetic retinopathy (DR). The extraction was done using GPT3.5 Turbo as of October 2023. OpenAI's GPT-3.5 Turbo significantly reduced the time taken for extraction. Concordance was highest at 100% for the extraction of the country of study, 64.7% for significant risk factors of DR, 47.1% for exclusion and inclusion criteria, and lastly 41.2% for odds ratio (OR) and 95% confidence interval (CI). The concordance levels seemed to indicate the complexity associated with each prompt. This suggests that OpenAI's GPT-3.5 Turbo may be adopted to extract simple information that is easily located in the text, leaving more complex information to be extracted by the researcher. It is crucial to note that the foundation model is constantly improving significantly with new versions being released quickly. Subsequent work can focus on retrieval-augmented generation (RAG), embedding, chunking PDF into useful sections, and prompting to improve the accuracy of extraction.

A practical model for effective eye care delivery in Southeast Asian rural communities: A proposal built based on experts' recommendations.

PURPOSE: To evaluate rural community-based eye care models from the perspective of community ophthalmology experts and suggest sustainable technological solutions for enhancing rural eye care delivery. METHODS: A semi-structured descriptive survey, using close-ended and open-ended questions, was administered to the experts in community ophthalmology sourced through purposive sampling. The survey was self-administered and was facilitated through online platforms or in-person meetings. Uniform questions were presented to all participants, irrespective of their roles. RESULTS: Surveyed participants (n = 22 with 15 from India and 7 from Nepal) in high-volume tertiary eye hospitals faced challenges with resources and rural outreach. Participants had mixed satisfaction with pre-operative screening and theatre resources. Delayed presentations and inexperienced surgeons contributed to the surgery complications. Barriers to rural eye care included resource scarcity, funding disparities, and limited infrastructure. In rural/peri-urban areas 87% of participants agreed with providing primary eye care services, with more than 60% of the experts not in agreement with the makeshift center model of eye care delivery. Key components for an effective eye care model are sustainability, accessibility, affordability, and quality. These can be bolstered through a healthcare management platform and a human-chain supply distribution system. CONCLUSION: Tailored interventions are crucial for rural eye care, emphasizing the need for stronger human resources, optimized funding, and community awareness. Addressing challenges pertinent to delayed presentation and surgical training is vital to minimizing complications, especially with advanced cataracts. Enhancements in rural eye care demand a comprehensive approach prioritizing accessibility, affordability, and consistent quality.