Current situation and prospect of teleophthalmology.

With the development of technology, doctors can diagnose and treat many diseases through telemedicine. At present, teleophthalmology is mainly used in screening and diagnosing some ocular diseases, monitoring chronic ocular diseases, as well as teleconsultation. With the increasing demand and application of teleophthalmology, some problems will gradually become prominent, such as insufficient equipment and staff, medical risks, patient acceptance and satisfaction, network security, privacy, and covering of medical insurance. The global pandemic of COViD-19 has unexpectedly brought telemedicine to the forefront of ophthalmic services, and may continue to change the way of ophthalmic diagnosis and treatment. With the development of artificial intelligence technology, the expansion of 5G communication network coverage, the standardized training of primary medical staff, and the introduction of relevant laws and regulations, teleophthalmology will become more improved, universal, and widely applied, so as to provide patients with sustainable medical services of higher quality.Copyright © 2021, Peking Union Medical College Hospital. All rights reserved.

The renin-angiotensin system in the eye

The renin–angiotensin system is major endocrine, paracrine, and autocrine system that has a notorious role in regulating hemodynamics and electrolyte balance, thus controlling blood pressure. Nonetheless, the functions of RAS are multiple and continue to expand, as its receptors, enzymes, and peptides have been identified in different organs/tissues, implying novel local effects of RAS and participation in the pathogenesis of different diseases in multiple organs, including the eyes. Vascularized, fibrous, and nervous structures of the eyes and their fluids express several RAS components including angiotensinogen, prorenin, renin, (P)RR, ACE, Ang II, AT1R, AT2R, ACE2, Ang 1-7, and Mas. Additionally, abundant RAS hormones are present in intraocular tissues implicating local production. Ocular RAS functions seem to be diverse;first, RAS is proposed to modulate aqueous humor biosynthesis and drainage, consequently regulating IOP. Exacerbation of ACE/ Ang II/ AT1R actions is observed in glaucoma, and blockage of this axis with ACEIs and ARBs is a feature that can be explored to reduce IOP and treat glaucoma. Second, impairment of RAS with exacerbation of ACE/ Ang II/ AT1R and depletion of ACE2/ Ang 1-7/ Mas culminate in an angiogenic, inflammatory, proliferative, and oxidative phenotype, which is tightly related to retinal vascular disorders such as diabetic retinopathy, age-related macular degeneration, and retinopathy of prematurity. Indeed, treatments blocking ACE/ Ang II/ AT1R or enhancing ACE2/ Ang 1-7/ Mas are reported to be beneficial to prevent or restrain the progression of these diseases. Finally, clinical manifestations of COVID-19 include ocular disorders such as conjunctivitis, dry eyes, eye pain, discharge, and blurred vision. ACE2 expression in ocular tissues may define ophthalmic susceptibility to SARS-CoV-2 infection. Moreover, SARS-CoV-2 entry mechanisms may cause depletion of ACE2 biological effects, which can contribute to RAS dysregulation and the ocular disorders observed in COVID-19. This chapter focuses on reviewing the components and functions of the ocular RAS, its implications for eye homeostasis, and the potential of RAS as a therapeutic target to treat ocular disorders, including glaucoma, diabetic retinopathy, age-related macular degeneration, and retinopathy of prematurity. © 2023 Elsevier Inc. All rights reserved.

Challenge Accepted: Retinopathy of Prematurity (ROP) During COVID-19.

The World Health Organization has identified retinopathy of prematurity (ROP) as one of the emerging causes of preventable childhood blindness in developing and middle-income countries. It is becoming a major public health problem in developing countries like India and China. ROP blindness in India is increasing due to the highest number of preterm births in the world, suboptimal neonatal care, lack of awareness, screening programs and treatment not in place, and increasing numbers of neonatal intensive care units (NICUs) and special newborn care units (SNCUs) opening all over the country without appropriate ophthalmic care. On top of it, heavier and late preterm babies are developing severe ROP due to the variable quality of neonatal services and insufficient optimal eye care in the NICU and SNCU. The situation become more precarious during the coronavirus disease 2019 (COVID-19) pandemic, and it became a challenge to motivate health workers and parents to keep the screening and treatment of ROP babies in place.

A Systematic Review of Economic Evaluations Conducted for Interventions to Screen, Treat, and Manage Retinopathy of Prematurity (ROP) in the United States, United Kingdom, and Canada.

PURPOSE: A systematic literature review (SLR) of economic evaluations (EE) conducted for interventions to screen, treat, and manage retinopathy of prematurity (ROP) in the United States (US), United Kingdom (UK), and Canada was performed. METHODS: The SLR accessed the MEDLINE, Embase, Cochrane, Web of Science, Health Business Elite, Econ. Lit, NHS EED, and Google Scholar databases over the period 1st January 2000 to 4th August 2021. The key Medical Subject Heading (MeSH) search terms used included: Retinopathy of prematurity, Cost-effectiveness analysis, Cost-utility analysis, Cost of illness, Cost-benefit analysis, Cost minimization analysis, Incremental cost-effectiveness ratio, Quality adjusted life years, return on investment, burden of illness, disability adjusted life years, and Economic evaluation. Screening was conducted using Covidence, and the risk of bias was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Data extraction was performed using MS Excel. RESULTS: 1,527 articles were examined with nine (9) papers identified, one (1) from the UK; two (2) from Canada and six (6) from the US. Cost-effectiveness analysis was the main form of EE conducted (n = 5) and telemedicine screening (n = 3) was found to be highly cost-effective for ROP with the ICER values ranging from £446 to £4,240 per Quality Adjusted Life Year (QALY) in 2021 figures. 73% of included studies complied with the CHEERS checklist for EE. CONCLUSIONS: ROP screening and treatment strategies reviewed were highly cost-effective. This review may assist eye health policymakers in planning nationwide screening and treatment programs to combat vision loss and blindness due to ROP.

Ocular Evaluation of Newborns Whose Mother Died Due to Sars-Cov-2 (Covid-19) Infection

BACKGROUND AND AIM: In the pregnancies of severe SARS-CoV-2, which resulted in maternal death, the fetus is more vulnarable in terms of being affected by systemic complications. The aim of this study is to evaluate the ocular findings of newborns whose mothers passed away due to SARS-CoV-2, by considering possible different modes of involvement. METHOD(S): Single-center retrospective observational study. A total of 9 newborns were evaluated ophthalmologically. Demographic data, polymerase chain reaction(PCR) test results and ophthalmological findings were collected. RESULT(S): Gestational age at ranged from 27 to 37 weeks (mean 31,55 +/- 3,16 weeks), and the birth weights varied from 990 g to 2160 g (mean 1481+/-397g). Mean ICU stay was 28.7 days. Positive PCR was positive for SARS-CoV-2 in 2 newborns.Ocular examination was performed within the first 30 days. Neonatal conjunctivitis (n=2), corneal edema (n=1), retinopathy of prematurity (ROP) (n=6) (treatment requiring ROP n=3) and intraretinal bleeding(n=2)was observed.One of the babies with a positive result had ROP that did not require treatment, and the other had conjunctivitis with intraretinal hemorrhage. CONCLUSION(S): Despite numerous studies, the impact of SARS-CoV-2 on the fetus remains unclear in many ways. Case reports indicate that maternal-fetal vertical transmission is not common.Exposure to intrauterine inflammation and placental changes may cause multisystemic problems in the neonatal period in exposed infants.The need for intensive care in the mother increases the possibility of fetal vascular malperfusion, premature birth rate and related problems.The detected ocular pathologies are not specific to SARS-CoV-2 infection.Additional controlled studies are required to correlate the findings with the disease. (Figure Presented).

Coats plus in prematurity.

BACKGROUND: Coats plus syndrome or cerebroretinal microangiopathy with calcifications and cysts (CMCC) is an exceedingly rare autosomal recessive disorder that predominantly affects the microvasculature in the retina, brain, bones, and gastrointestinal system. Unlike Coats disease, CMCC is bilateral and affects multiple organ systems. MATERIALS AND METHODS: Case report. RESULTS: We report the case of two brothers with Coats Plus syndrome who presented with variable phenotypic expression. One sibling (Patient 1) was thought to have atypical retinopathy of prematurity and was only diagnosed with Coats plus after his older brother (Patient 2) presented with a seizure and a left upper extremity tremor at 4 years of age. The CTC1 mutation was confirmed in both patients. Aggressive treatment with laser photocoagulation and intravitreal bevacizumab dramatically improved the retinal vascular and exudative changes. CONCLUSION: Coats Plus syndrome can have a variable phenotypic presentation, including retinal vascular findings. This rare genetic disease should be in the differential diagnosis in patients who present with atypical retinal pathology, including Retinopathy of Prematurity, Familial Exudative Vitreoretinopathy, or Coats disease associated with non-specific multiorgan abnormalities.

Evaluation of a revised care plan for babies with retinopathy of prematurity during SARS-CoV-2 pandemic in India.

Purpose: To analyze the impact of a revised care plan for retinopathy of prematurity (ROP) during SARS-CoV-2 pandemic in a tertiary eye care facility in eastern India. Methods: In a retrospective study, we analyzed the medical records of babies managed for ROP during the peak of the SARS-CoV-2 pandemic, with particular reference to the challenges, and the revised strategies addressing travel restrictions for five months, from April to August 2020. The strategy included selective referral (babies with higher treatment probability), longer follow-up intervals (babies with non-alarming findings), use of locally available workforce, and teleconsultation whenever feasible. Results: In the given period, 222 babies were examined versus 624 in the preceding year (P = 0.001). The average gestational age, birth weight, and postmenstrual age at presentation were 30.4 weeks, 1.31 kg, and 37.7 weeks, respectively. The first examination was on time in 40.1% of babies but was delayed by a median of 23 days in the remaining babies. In the cohort, 56.7% of babies had any ROP, and 27.9% required treatment (versus 8.8% in the previous year; P < 0.001). The intravitreal anti-vascular growth factor (anti-VEGF) injection was more often used than in the previous year (n = 72 vs 36; P < 0.0001). The treatment outcome was comparable before and after the SARS-CoV-2 lockdown period. There was no report of health issues among the care providers attributable to ROP care. Conclusion: The revised strategy resulted in a smaller pool of babies screened but a larger proportion of babies treated for ROP. This strategy could be used more profitably in future ROP care.

Preferred practice guidelines for retinopathy of prematurity screening during the COVID-19 pandemic.

Retinopathy of prematurity (ROP) is the leading cause of preventable infant blindness in the world and predominantly affects babies who are born low birth weight and premature. India has the largest number of surviving preterm births born annually. ROP blindness can be largely prevented if there is a robust screening program which detects treatment requiring disease in time. ROP treatment must be provided within 48 h of reaching this threshold of treatment making it a relative emergency. During the severe acute respiratory syndrome-coronavirus disease 2019 pandemic in 2020 ROP screening was disrupted throughout the world due to lockdowns and restriction of movement of these infants, their families, specialists and healthcare workers. The Indian ROP Society issued guidelines for ROP screening and treatment in March 2020, which was aimed at preserving the chain-of-care despite the potential limitations and hazards during the (ongoing) pandemic. This preferred practice guideline is summarized in this manuscript.

Artificial intelligence: the unstoppable revolution in ophthalmology.

Artificial intelligence (AI) is an unstoppable force that is starting to permeate all aspects of our society as part of the revolution being brought into our lives (and into medicine) by the digital era, and accelerated by the current COVID-19 pandemic. As the population ages and developing countries move forward, AI-based systems may be a key asset in streamlining the screening, staging, and treatment planning of sight-threatening eye conditions, offloading the most tedious tasks from the experts, allowing for a greater population coverage, and bringing the best possible care to every patient. This paper presents a review of the state of the art of AI in the field of ophthalmology, focusing on the strengths and weaknesses of current systems, and defining the vision that will enable us to advance scientifically in this digital era. It starts with a thorough yet accessible introduction to the algorithms underlying all modern AI applications. Then, a critical review of the main AI applications in ophthalmology is presented, including diabetic retinopathy, age-related macular degeneration, retinopathy of prematurity, glaucoma, and other AI-related topics such as image enhancement. The review finishes with a brief discussion on the opportunities and challenges that the future of this field might hold.

Integrins: An Important Link between Angiogenesis, Inflammation and Eye Diseases.

Integrins belong to a group of cell adhesion molecules (CAMs) which is a large group of membrane-bound proteins. They are responsible for cell attachment to the extracellular matrix (ECM) and signal transduction from the ECM to the cells. Integrins take part in many other biological activities, such as extravasation, cell-to-cell adhesion, migration, cytokine activation and release, and act as receptors for some viruses, including severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2). They play a pivotal role in cell proliferation, migration, apoptosis, tissue repair and are involved in the processes that are crucial to infection, inflammation and angiogenesis. Integrins have an important part in normal development and tissue homeostasis, and also in the development of pathological processes in the eye. This review presents the available evidence from human and animal research into integrin structure, classification, function and their role in inflammation, infection and angiogenesis in ocular diseases. Integrin receptors and ligands are clinically interesting and may be promising as new therapeutic targets in the treatment of some eye disorders.

The safety and feasibility of the screening for retinopathy of prematurity assisted by telemedicine network during COVID-19 pandemic in Wuhan, China.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) epidemic, due to the traffic blockade and the shortage of medical resources, more and more premature infants could not receive timely and effective ROP screening, which delayed treatment and even caused children blindness. Therefore, how to carry out ROP screening safely and effectively during the epidemic was very important and urgent. This study aimed to evaluate the safety and feasibility of ROP screening assisted by telemedicine network during COVID-19 outbreak. METHODS: This retrospective study was conducted at Wuhan Children's hospital in Wuhan, China, from January to October, 2020. The measures which were performed to make the ROP screening more safe and effective were summarized and the comparison between ROP screening assisted by telemedicine network in 2020 and usual screening in 2019 were analyzed. RESULTS: A total of 267 outpatient infants completed ROP screening. The median gestational age was 32 weeks (30w to 34w) and the median birth weight was 1780 g (1460 g to 2100 g). Meanwhile, 149 (55.8%) out of 267 infants were males. During January to May in 2020, 86 screening appointments were received, among which 67 (77.9%) were from telemedicine platform online. The completing percentage of total online ROP appointments was higher than that of total face-to-face appointments (58.1% VS 22. 1%, P = 0.018). As for the number of infants screened between 2020 and 2019 from Februaryto October, 54 infants completed ROP screening in 2020, which was higher than that (51participants) in 2019 on September. Furthermore, compared with the usual screening in 2019, ROP screening assisted by telemedicine network in 2020 had smaller gestational age (32w VS 33w, p<0.001) and lower birth weight (1780 g VS 1900 g, p = 0.001). However, of the 267 infants screened, 18(6.7%) had ROP while the percentage of ROP screened in 2019 was the same (44[6.7%]). During follow-up, none of medical staffs was infected and no adverse reaction was reported. CONCLUSIONS: The screening for retinopathy of prematurity assisted by telemedicine network was safe and feasible during the COVID-19 pandemic. Preventive measures before and after screening were very necessary, which could effectively avoid cross infection.

Aerosol containment box for laser treatment of retinopathy of prematurity in COVID-19 pandemic.

Type 1 retinopathy of prematurity (ROP) requires emergency intervention and laser is an established modality of treatment. Laser treatment for ROP under topical anesthesia can be considered as an aerosol-generating procedure due to crying that puts health care workers at high risk of COVID-19 transmission. Aerosol containment box (ACB) is known to minimize aerosol transmission and there are reports of ROP laser done through incubator. Combining these two ideas, we describe a new application of ACB with suction for laser treatment of ROP thereby, reducing risk to health care team without compromising timely effective, and safe treatment for ROP.