Proliferative vitreoretinopathy: an update on the current and emerging treatment options.

Proliferative vitreoretinopathy (PVR) remains the main cause of failure in retinal detachment (RD) surgery and a demanding challenge for vitreoretinal surgeons. Despite the large improvements in surgical techniques and a better understanding of PVR pathogenesis in the last years, satisfactory anatomical and visual outcomes have not been provided yet. For this reason, several different adjunctive pharmacological agents have been investigated in combination with surgery. In this review, we analyze the current and emerging adjunctive treatment options for the management of PVR and we discuss their possible clinical application and beneficial role in this subgroup of patients.

LATE RECURRENCE OF RETINAL DETACHMENT: Incidence, Clinical Features, and Surgical Outcomes.

PURPOSE: To describe and evaluate demographics, clinical features, prognostic factors, rate of success of surgery, incidence, and visual outcomes in patients with a late recurrence of rhegmatogenous retinal detachment over a 10-year period at a large tertiary referral eye center. METHODS: A retrospective, observational case series of patients with late recurrence of retinal detachment, defined as redetachment after at least six months of total reattachment in non-proliferative vitreoretinopathy (PVR) rhegmatogenous retinal detachment, after pars plana vitrectomy (PPV) surgery with gas tamponade. RESULTS: Thirty-nine patients had a late recurrence of rhegmatogenous retinal detachment of 16,396 rhegmatogenous retinal detachment operations. The mean of time between the first retinal detachment (RD) surgery and redetachment was 122.7 (SD 115) weeks. On presentation with late recurrence, 72% of eyes were pseudophakic and 64% were macula-off. In 28 eyes, small breaks were found. Thirty-eight percent had established PVR (PVR-C in 80%). Ninety-five percent underwent PPV. Gas was used in 61%. The initial secondary success rate was 64%. Initial best-corrected visual acuity was 1.32 logarithm of the minimum angle of resolution (logMAR) (6/120) and final was 0.8 logMAR (6/38; P value 0.002). CONCLUSION: Late recurrence of retinal detachment is rare. It is characterized by small retinal breaks that may be difficult to visualize. Although cases can be treated with favorable anatomical results, visual outcomes are often less good and the success rate is lower.

CLINICAL FEATURES AND SURGICAL OUTCOMES OF SCLERAL BUCKLE SURGERY FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: Moorfields Buckle Study.

PURPOSE: Long-term study to evaluate the clinical and surgical outcomes of scleral buckle (SB) surgery for primary rhegmatogenous retinal detachment (RRD) at a large tertiary eye center. METHODS: Noncomparative, retrospective case series of 589 eyes of 569 patients with primary RRD who underwent SB surgery between 2004 and 2022 with a median follow-up of 6 months. The main outcome measures were best-corrected visual acuity, surgical outcomes, complications, and classification of RRD. RESULTS: At baseline, 447/589 (76.1%) round hole RRD, and 133/589 (22.7%) retinal dialysis RRD. Overall primary SB success rate was 83.7% for all retinal detachment subtypes, with round hole retinal detachment 84.8% and dialysis RRD 81.2%. Overall, the baseline best-corrected visual acuity was 0.42 logarithm of the minimum angle of resolution (logMAR) and the final best-corrected visual acuity was 0.26 logMAR ( P < 0.0001). In macula-off RRD, the best-corrected visual acuity significantly improved from 0.79 to 0.48 logMAR ( P < 0.0001). In patients with macula-on RRD, it improved from 0.19 to 0.12 logMAR ( P = 0.014). Binary logistic regression showed registrar surgeon grade (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.01-0.55), and partial or complete posterior vitreous detachment (OR 0.21, 95% CI 0.10-0.49) was associated with reduced odds of primary success. Higher surgical failure was associated with low pre-fellowship SB surgeon experience ( P = 0.024). CONCLUSION: Favorable visual and functional outcomes have been reported in a large series of SB for primary retinal detachment, mainly for patients with round hole RRD and retinal dialysis RRD.

BASELINE SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHIC RETINAL LAYER FEATURES IDENTIFIED BY ARTIFICIAL INTELLIGENCE PREDICT THE COURSE OF CENTRAL SEROUS CHORIORETINOPATHY.

PURPOSE: To identify optical coherence tomography (OCT) features to predict the course of central serous chorioretinopathy (CSC) with an artificial intelligence-based program. METHODS: Multicenter, observational study with a retrospective design. Treatment-naïve patients with acute CSC and chronic CSC were enrolled. Baseline OCTs were examined by an artificial intelligence-developed platform (Discovery OCT Fluid and Biomarker Detector, RetinAI AG, Switzerland). Through this platform, automated retinal layer thicknesses and volumes, including intaretinal and subretinal fluid, and pigment epithelium detachment were measured. Baseline OCT features were compared between acute CSC and chronic CSC patients. RESULTS: One hundred and sixty eyes of 144 patients with CSC were enrolled, of which 100 had chronic CSC and 60 acute CSC. Retinal layer analysis of baseline OCT scans showed that the inner nuclear layer, the outer nuclear layer, and the photoreceptor-retinal pigmented epithelium complex were significantly thicker at baseline in eyes with acute CSC in comparison with those with chronic CSC ( P < 0.001). Similarly, choriocapillaris and choroidal stroma and retinal thickness (RT) were thicker in acute CSC than chronic CSC eyes ( P = 0.001). Volume analysis revealed average greater subretinal fluid volumes in the acute CSC group in comparison with chronic CSC ( P = 0.041). CONCLUSION: Optical coherence tomography features may be helpful to predict the clinical course of CSC. The baseline presence of an increased thickness in the outer retinal layers, choriocapillaris and choroidal stroma, and subretinal fluid volume seems to be associated with acute course of the disease.

Prediction of chronic central serous chorioretinopathy through combined manual annotation and AI-assisted volume measurement of flat irregular pigment epithelium.

INTRODUCTION: The aim of this study is to investigate the role of an artificial intelligence (AI)-developed OCT program to predict the clinical course of central serous chorioretinopathy (CSC ) based on baseline pigment epithelium detachment (PED) features. METHODS: Single-center, observational study with a retrospective design. Treatment-naïve patients with acute CSC and chronic CSC were recruited and OCTs were analyzed by an AI-developed platform (Discovery OCT Fluid and Biomarker Detector, RetinAI AG, Switzerland), providing automatic detection and volumetric quantification of PEDs. Flat irregular PED presence was annotated manually and afterwards measured by the AI program automatically. RESULTS: 115 eyes of 101 patients with CSC were included, of which 70 were diagnosed with chronic CSC and 45 with acute CSC. It was found that patients with baseline presence of foveal flat PEDs and multiple flat foveal and extrafoveal PEDs had a higher chance of developing chronic form. AI-based volumetric analysis revealed no significant differences between the groups. CONCLUSIONS: While more evidence is needed to confirm the effectiveness of AI-based PED quantitative analysis, this study highlights the significance of identifying flat irregular PEDs at the earliest stage possible in patients with CSC, to optimize patient management and long-term visual outcomes.

Impact of COVID-19 pandemic on eye cancer care in United Kingdom.

The COVID-19 pandemic has had an unprecedented impact on the National Health Service in United Kingdom. The UK Ocular Oncology Services evaluated the impact on the adult eye cancer care in the UK. All four adult Ocular Oncology centres participated in a multicentre retrospective review comparing uveal melanoma referral patterns and treatments in a 4-month period during the national lockdown and first wave of the COVID-19 pandemic in 2020 with corresponding periods in previous 2 years. During the national lockdown, referral numbers and confirmed uveal melanoma cases reduced considerably, equalling to ~120 fewer diagnosed uveal melanoma cases compared to previous 2 years. Contrary to the recent trend, increased caseloads of enucleation and stereotactic radiosurgery (p > 0.05), in comparison to fewer proton beam therapy (p < 0.05), were performed. In the 4-month period following lockdown, there was a surge in clinical activities with more advanced diseases (p < 0.05) presenting to the services. As the COVID-19 pandemic continues to mount pressure and reveal its hidden impact on the eye cancer care, it is imperative for the Ocular Oncology Services to plan recovery strategies and innovative ways of working.

Clinical presentations and surgical outcomes of intraocular foreign body presenting to an ocular trauma unit.

OBJECTIVES: To describe, evaluate, and identify the characteristics, prognostic factors, and visual outcomes in patients with intraocular foreign body (IOFB) in a Latin American population. METHODS: A retrospective, observational case-series of patients with a diagnosis of IOFB. Variables analyzed included age, gender, initial and final best correct visual acuity (BCVA), ocular trauma score, intraocular pressure, mechanism of injury, material and number of IOFB, zone of injury, timing of primary repair and IOFB removal, complications, and follow up. RESULTS: Sixty-one patients with IOFB were identified of which 97% were male with a mean age of 37.9 years (SD 2.16). The most common IOFB location was intravitreal (43%). IOFBs were metallic in 78%, vegetal in 3%, and other materials in 11%. Primary repair and secondary IOFB removal were performed at a mean timepoint of 3 days and 5 days, respectively. Systemic and topical antibiotics were administered to all patients. The initial BCVA was 1.62 logMAR and the final was 0.6 logMAR, which was statistically significant (Pearson's chi-squared test, p value 0.01). No cases of endophthalmitis were seen. CONCLUSION: IOFB removal can be delayed when there are no signs of infection or evidence of retinal detachment, without an increased risk of endophthalmitis and a negative impact on visual outcomes. Use of topical and systemic antibiotics appear sufficient to prevent endophthalmitis in these cases.

Association of retinal detachment with age 50 years or younger at onset in patients with acute retinal necrosis.

BACKGROUND: Due to the guarded prognosis of acute retinal necrosis (ARN), it is relevant to develop a strategy to early categorize those patients in a higher risk of worse outcomes. The purpose of this study is to describe clinical features and predictive factors for retinal detachment (RD) in patients with ARN. METHODS: Retrospective observational case series of 34 adult patients (38 eyes) with ARN examined between January 2005 and July 2015 in the National Eye Institute (Bethesda, USA), the Department of Ophthalmology, University of Chile (Santiago, Chile), and APEC (CDMX, Mexico). RESULTS: A total of 16 males and 18 females with a mean age at presentation of 44.5 ± 16.8 years were included. Twenty-seven patients (79.4%) received intravenous acyclovir as first-line treatment, and 7 patients received either oral antiviral (4 patients) or oral plus intravitreal antiviral (3 patients). All subjects were treated with prednisone, with a mean initial dose of 57.7 ± 16.3 mg per day. Seventeen patients (50.0%) developed retinal detachment. An association of retinal detachment with age at onset was observed (p = 0.04), with patients younger than 50 years presenting a higher risk (OR = 14.86, p = 0.0009). Additionally, patients in this higher risk group had more inflammation in both anterior chamber and vitreous (p = 0.04 and 0.03, respectively). No other predictive factor for retinal detachment was found in the present study. CONCLUSIONS: RD represents an important complication in patients with ARN. Younger patients may be at higher risk of this complication, possibly secondary to the presence of a higher level of inflammation.

LATE PRESENTATION OF RETINAL DETACHMENT: CLINICAL FEATURES AND SURGICAL OUTCOMES.

PURPOSE: To describe and evaluate demographic, clinical features, prognostic factors, and rate of success of surgery and visual outcomes in patients with late presentation of retinal detachment. METHODS: A retrospective, comparative, observational case series of patients with late presentation retinal detachment, defined as retinal detachment with the loss of central vision for 4 weeks or more, over a period of 12 months. RESULTS: The mean of onset of central visual loss was 12.7 weeks (SD, 21.3). Proliferative vitreoretinopathy at the first operation was identified in 69% of eyes. The overall primary success rate was 69.2%, significantly less than that was found in outcomes for nonselected retinal detachment (primary success rate, 86%; P = 0.006). The initial best-corrected visual acuity was 20/500, and the final was 20/160 (P = 0.0027). There were no identifiable statistically significant socioeconomic factors related to late presentation. CONCLUSION: A high rate of established proliferative vitreoretinopathy on presentation was identified, and although cases can be treated with good anatomical results, visual outcomes are often less favorable. Primary surgical success is lower, and more reoperations are required compared with standard retinal detachments.

[Management of diabetic retinopathy using telemedicine and network integration]. / Modelo de manejo en red y por telemedicina de la retinopatía diabética en dos comunas del Servicio de Salud Metropolitano Oriente.

BACKGROUND: If we are able to increase the resolution of complex medical problems at primary health care levels, we would improve the efficiency of the health care systems and would reduce the burden of specialists. AIM: To describe the result of a telemedicine and network management of diabetic retinopathy supervised by an ophthalmological service. MATERIAL AND METHODS: Diabetic patients attended in primary health care centers of the East Metropolitan Health Service in Santiago, Chile, derived for 45° digital retinographies were evaluated using telemedicine by the ophthalmologists of the base hospital. These professionals screened for diabetic retinopathy and classified it. Those patients with diabetic retinopathy were derived to the base hospital for specialized management. RESULTS: Of 2,566 patients evaluated, 22% had signs of diabetic retinopathy, 75% did not have the condition and 2% could not be evaluated with retinography. Seventy percent of patients with retinopathy, equivalent to only fifteen percent of total diabetics, were referred to the specialists for treatment. CONCLUSIONS: This model allowed a reduction of referrals to ophthalmologists, reducing the burden of secondary and tertiary health care systems.

The digital age in retinal practice.

This editorial examines the transformative impact of the digital revolution on retinal practice, highlighting how technological advances are transforming patient care and pushing the boundaries of ophthalmology. It explores key areas of progress, including personalised medicine through big data, artificial intelligence and advanced imaging techniques; the role of telemedicine and home OCT in improving access and monitoring; advances in robotic surgery and 3D printing for vitreoretinal procedures; and the potential of large language models in patient education and communication. While highlighting the immense potential of these innovations, the editorial also addresses ethical considerations related to privacy and algorithmic bias. It emphasises the importance of multidisciplinary collaboration and maintaining a patient-centred approach in the digital age.

Iris Reconstruction: A Surgeon's Guide.

Objectives: The aim of this review paper is to summarise surgical options available for repairing iris defects at the iris-lens plane, focusing on suturing techniques, iridodialysis repair, and prosthetic iris devices. Methods: A thorough literature search was conducted using multiple databases, including Medline, PubMed, Web of Science Core Collection, and the Cochrane Library, from inception to February 2024. Relevant studies were screened based on predefined criteria, and primary references cited in selected articles were also reviewed. Results: Various surgical techniques were identified for iris defect repair. Suturing methods such as interrupted full-thickness sutures and the McCannel technique offer solutions for smaller defects, while iridodialysis repair techniques address detachment of the iris from the ciliary body. Prosthetic iris devices, including iris-lens diaphragm devices, endocapsular capsular tension ring-based devices, and customizable artificial iris implants, provide options for larger defects, each with its own advantages and limitations. Conclusions: Successful iris reconstruction requires a personalised approach considering factors like defect size, ocular comorbidities, and patient preference. Surgeons must possess a thorough understanding of available techniques and prosthetic devices to achieve optimal outcomes in terms of both visual function and, nonetheless, cosmetic appearance.

Perspectives on the currently available pharmacotherapy for wet macular degeneration.

INTRODUCTION: Wet age-related macular degeneration (w-AMD) is a leading cause of visual impairment globally, with its prevalence expected to rise alongside increasing life expectancy. The current standard treatment involves frequent intravitreal injections of anti-VEGF agents, which although revolutionary, pose significant burdens on both patients and healthcare services. AREAS COVERED: This review explores current and emerging pharmaceutical treatments for w-AMD, focusing on their pharmacokinetics, pharmacodynamics, efficacy, and safety. Promising developments include extending treatment intervals with newer anti-VEGF agents like brolucizumab and faricimab, biosimilars offering cost-effective options, and exploring innovative drug delivery methods such as subretinal gene therapy. Combination therapies, gene therapies, and novel agents like KSI-301 and OPT-302 show potential for improving treatment outcomes and reducing treatment burden. EXPERT OPINION: While current treatments for w-AMD have significantly advanced with the advent of anti-VEGF therapies, their limitations in terms of treatment burden and incomplete responses have spurred research into diverse alternative approaches. These innovative strategies offer hope for improving patient outcomes and reducing healthcare burdens, suggesting a promising future for w-AMD management.

Assessing large language models' accuracy in providing patient support for choroidal melanoma.

PURPOSE: This study aimed to evaluate the accuracy of information that patients can obtain from large language models (LLMs) when seeking answers to common questions about choroidal melanoma. METHODS: Comparative study comparing frequently asked questions from choroidal melanoma patients and queried three major LLMs-ChatGPT 3.5, Bing AI, and DocsGPT. Answers were reviewed by three ocular oncology experts and scored as accurate, partially accurate, or inaccurate. Statistical analysis compared the quality of responses across models. RESULTS: For medical advice questions, ChatGPT gave 92% accurate responses compared to 58% for Bing AI and DocsGPT. For pre/post-op questions, ChatGPT and Bing AI were 86% accurate while DocsGPT was 73% accurate. There were no statistically significant differences between models. ChatGPT responses were the longest while Bing AI responses were the shortest, but length did not affect accuracy. All LLMs appropriately directed patients to seek medical advice from professionals. CONCLUSION: LLMs show promising capability to address common choroidal melanoma patient questions at generally acceptable accuracy levels. However, inconsistent, and inaccurate responses do occur, highlighting the need for improved fine-tuning and oversight before integration into clinical practice.

Prospective validation of a virtual post-operative clinic in vitreoretinal surgery.

PURPOSE: To evaluate the clinical efficacy and safety of asynchronous virtual post-operative assessments following vitreoretinal surgery and procedures compared to traditional face-to-face assessments in a high-volume tertiary eye centre. METHODS: Prospective comparative clinical series study of patients who had undergone vitreoretinal surgery or post-laser retinopexy. Patients received both virtual and face-to-face assessments. The virtual assessment included clinical questions, visual acuity measurement, and virtual retinal imaging using ultra-wide field (UWF) imaging and macular optical coherence tomography (OCT). Face-to-face assessments involved standard clinical examinations. RESULTS: We included 142 patients undergoing a variety of vitreoretinal procedures. We showed comparable results between virtual and face-to-face assessments in both, post-operative and post-laser treatments. UWF imaging with macular OCT demonstrated potential for effective virtual post-operative assessment. The virtual assessment has a sensitivity of 91% and specificity of 100% for detecting retinal detachments with 100% specificity and 100% sensitivity for detecting new retinal tears or insufficient laser treatment. CONCLUSIONS: The implementation of asynchronous virtual post-operative assessments following a variety of vitreoretinal procedures is a promising alternative to traditional face-to-face assessments. Virtual assessments using UWF imaging and macular OCT showed high sensitivity and specificity. Virtual post-operative clinics offer the potential to improve patient access and decrease the clinical burden, especially with the continuing evolution of telemedicine technologies and imaging modalities.

New high-resolution prototype versus standard spectralis optical coherence tomography in patients with central serous chorioretinopathy.

PURPOSE: To assess the accuracy of High-Resolution OCT in detecting biomarkers associated with central serous chorioretinopathy (CSC) compared to standard OCT. METHODS: We conducted a cross-sectional study involving CSC patients who underwent High-Resolution and standard OCT during the same visit. Using the SPECTRALIS High-Res OCT device (Heidelberg Engineering, Heidelberg, Germany), macular B-scans were obtained and compared with those acquired using a SPECTRALIS HRA + OCT device (Heidelberg Engineering, Heidelberg, Germany). Qualitative assessments were performed, and statistical analyses compared the performance of both OCT modalities. RESULTS: Thirty-one patients diagnosed with CSC were included with a mean age of 56.3 years (± 10.2). Among them, 29% (n = 9) were classified as acute CSC (aCSC), while 71% (n = 22) had chronic CSC (cCSC). High-Resolution OCT outperformed standard OCT in detecting microstructural changes in the outer retinal layers, including a higher prevalence of disrupted interdigitation zone (IZ) (29% vs. 6%, p = 0.003) and retinal pigment epithelium (RPE) disruption (12% vs. 2%, p = 0.0024). Intergrader agreement was high (Cohen's Kappa = 0.85). CONCLUSION: High-Resolution OCT demonstrates promise in identifying critical biomarkers associated with CSC, particularly disruptions in the IZ and RPE. Further validation in larger cohorts is required to confirm their clinical relevance in patients with CSC.

Rhegmatogenous retinal detachment in choroidal melanoma: clinical features and surgical outcomes.

PURPOSE: To describe the clinical features, prognostic factors, safety and rate of success of surgery and visual outcomes in patients with rhegmatogenous retinal detachment (RRD) and choroidal melanoma (CM). METHODS: A retrospective, observational case-series of 21 patients with rhegmatogenous retinal detachment or combined tractional-rhegmatogenous retinal detachment in patients with choroidal melanoma over a period of 20 years. RESULTS: Nineteen patients were included in the final analysis. The mean elevation of CM was 4.0 mm and the mean largest diameter was 11.0 mm. RRD occurred after the CM treatment in 14 eyes at a mean interval of 44.2 months. The RRD was macula-on RRD in 6 eyes, there was posterior vitreous detachment (PVD) in 15 and PVR in 7 eyes. BCVA at presentation was 0.71 logMAR and final was 1.5 logMAR (p = 0.01). The primary surgical success rate was 59%. No intraocular or extraocular tumour dissemination occurred. Mean follow-up was 66 months. CONCLUSION: RRD in patients with CM is uncommon but requires multidisciplinary management. Anatomical results are favourable but visual outcomes are poor due to a combination of factors related to melanoma treatment, macular retinal detachment and PVR. Vitrectomy as a surgical intervention for RRD in treated CM appears to be safe in terms tumour dissemination.

Artificial Intelligence-Enhanced OCT Biomarkers Analysis in Macula-off Rhegmatogenous Retinal Detachment Patients.

Purpose: To identify optical coherence tomography (OCT) biomarkers for macula-off rhegmatogenous retinal detachment (RRD) with artificial intelligence (AI) and to correlate these biomarkers with functional outcomes. Methods: Patients with macula-off RRD treated with single vitrectomy and gas tamponade were included. OCT volumes, taken at 4 to 6 weeks and 1 year postoperative, were uploaded on an AI-derived platform (Discovery OCT Biomarker Detector; RetinAI AG, Bern, Switzerland), measuring different retinal layer thicknesses, including outer nuclear layer (ONL), photoreceptor and retinal pigmented epithelium (PR + RPE), intraretinal fluid (IRF), subretinal fluid, and biomarker probability detection, including hyperreflective foci (HF). A random forest model assessed the predictive factors for final best-corrected visual acuity (BCVA). Results: Fifty-nine patients (42 male, 17 female) were enrolled. Baseline BCVA was 0.5 logarithmic minimum angle of resolution (logMAR) ± 0.1, significantly improving to 0.3 ± 0.1 logMAR at the final visit (P < 0.001). Average thickness analysis indicated a significant increase after the last follow-up visit for ONL (from 95.16 ± 5.47 µm to 100.8 ± 5.27 µm, P = 0.0007) and PR + RPE thicknesses (60.9 ± 2.6 µm to 66.2 ± 1.8 µm, P = 0.0001). Average occurrence rate of HF was 0.12 ± 0.06 at initial visit and 0.08 ± 0.05 at last follow-up visit (P = 0.0093). Random forest model revealed baseline BCVA as the most critical predictor for final BCVA, followed by ONL thickness, HF, and IRF presence at the initial visit. Conclusions: Increased ONL and PR-RPE thickness associate with better outcomes, while HF presence indicates poorer results, with initial BCVA remaining a primary visual predictor. Translational Relevance: The study underscores the role of novel biomarkers like HF in understanding visual function in macula-off RRD.