Bridging gaps in ophthalmology residency programs: the link between practice, training and confidence in ocular examination and gonioscopy for diagnosing glaucoma, a blinding disease.

BACKGROUND: To evaluate real-world utilization of gonioscopy for diagnosing glaucoma among ophthalmologists with diverse subspecialties, and understand current perceptions of teaching, training, and confidence in gonioscopy. METHODS: A nationwide anonymous online survey was conducted among practicing ophthalmologists, querying about demographics, professional experience, practice of routine ocular examination for glaucoma and perceptions of confidence in performing them. RESULTS: 136 ophthalmologists participated in the survey, with various levels of experience from residency to over twenty years of ophthalmology practice. Glaucoma specialists comprised 23 (16.9%) of the participants. Of the non-glaucoma-specialist respondents, only 33 (29.2%) expressed being highly confident in interpreting gonioscopic findings, which correlated significantly with their self-reported inadequate level of training in gonioscopy during residency (p < 0.001) and even more so with their low frequency of implementing gonioscopy in routine examinations (p < 0.001). The commonly cited reasons for the low practice of gonioscopy were insufficient time allotted to examinations and lack of experience, knowledge or equipment. CONCLUSIONS: Gonioscopy is fundamental to the detection of glaucoma. This study reveals underutilization of gonioscopy in the practice of ophthalmology and its association with lower training opportunities, calling for expedited changes in the residency's curriculum, alongside measures to promote its use in clinical practice.

Ocular injuries associated with motor vehicle accidents: long term effects on quality of life.

PURPOSE: To describe the prevalence and outcome of motor vehicle accidents-associated ocular injuries. METHODS: A survey of patients who presented to the emergency room at a level 1 trauma center with motor vehicle accidents-associated ocular injuries. A patient questionnaire and review of clinical notes were conducted for all patients. RESULTS: Of 274 motor vehicle accident victims with ocular injuries who presented to the emergency room, 40 (15%) responded to the survey. Over half of them were driving a vehicle, and most reported wearing a seat belt or a helmet. Most ocular injuries were mild. The most common injuries were bone fractures, subconjunctival hemorrhage, eyelid involvement and corneal injury. Most respondents had no change in vision and perceived their ocular involvement as a minor part of their injury. Most respondents returned to work and to driving within a year. CONCLUSION: Our study sheds light on the details and extent of ocular involvement and the visual ability to perform daily activities following motor vehicle accidents.

Long-Term Evaluation of Pseudoexfoliation Syndrome Post-Cataract Extraction.

The study aimed to examine the effect of cataract extraction on ophthalmologists' ability to detect pseudoexfoliation (PXF) syndrome. A total of 31 patients admitted for elective cataract surgery were enrolled in this prospective comparative study. Prior to surgery, patients underwent slit-lamp examination and gonioscopy conducted by experienced glaucoma specialists. Subsequently, patients were re-examined by a different glaucoma specialist and comprehensive ophthalmologists. Pre-operatively, 12 patients were diagnosed with PXF on the basis of a Sampaolesi line (100%), anterior capsular deposits (83%), and pupillary ruff deposits (50%). The remaining 19 patients acted as controls. All patients were re-examined 10-46 months post-operatively. Of the 12 patients with PXF, 10 (83%) were correctly diagnosed post-operatively by glaucoma specialists and 8 (66%) by comprehensive ophthalmologists. There was no statistically significant difference in PXF diagnosis. However, detection of anterior capsular deposits (p = 0.02), Sampaolesi lines (p = 0.04), and pupillary ruff deposits (p = 0.01) were significantly lower post-operatively. Diagnosis of PXF is challenging in pseudophakic patients as the anterior capsule is removed during cataract extraction. Therefore, PXF diagnosis in pseudophakic patients relies mainly on the presence of deposits at other anatomical sites, and careful attention to these signs is required. Glaucoma specialists may be more likely than comprehensive ophthalmologists to detect PXF in pseudophakic patients.

Gender related trends among Israeli ophthalmologists professional career and personal life performance.

BACKGROUND: Gender-diversity trends in ophthalmology in Israel have not been studied despite a high proportion of female ophthalmologists. Our purpose was to evaluate gender-related trends in ophthalmology professional career and personal life performance in early and advanced careers in Israel. METHODS: A survey based on a nationwide voluntary anonymous web questionnaire was distributed to the members of the Israeli Ophthalmological Society. The questionnaire included questions referring to professional career and personal life performance. Gender differences were analyzed. RESULTS: Out of 252 respondents, 116 (46%) were women, with a mean age of 47.97 + -11.3 and 53.18 + -12.4 (P = 0.01) years, respectively. Marital status, post-residency fellowship performance or duration, an additional academic degree, academic appointments, and managerial positions were similar between genders. Fellowship predominance of males was found in cornea/cataract/refractive and of females in strabismus, pediatric ophthalmology, and neuro-ophthalmology (P < 0.01, P = 0.032, respectively). Men had significantly more publications and appointments in peer review journals and work hours (P = 0.04 and P = 0.02, P = 0.027, respectively). Both genders responded similarly regarding work satisfaction, combination between family life and work. More women felt inequity during and post-residency in clinical (P = 0.011, P = 0.001, respectively) and surgical work (P = 0.001, P = 0.035, respectively). More women experienced inappropriate remarks from patients and sexual harassment (P = 0.001, P < 0.001, respectively), and supported the need for affirmative action (P < 0.0001). CONCLUSIONS: Several gender disparities were found among ophthalmologists in Israel, including subspecialties distributions, publications, appointments in peer review journals, working hours, work inequity sense, harassment events, and support the need for affirmative action.

Optical Coherence Tomography Angiography for the Differentiation of Glaucoma from Pituitary Macroadenoma Related Optic Disc Measurements.

OBJECTIVE: To determine the potential of optical coherence tomography (OCT) and OCT angiography (OCTA) to distinguish between glaucoma and pituitary macroadenoma by optic disc appearance. METHODS: This prospective case-control study comprised 31 patients: 23 with glaucoma (18 male, 5 female) and 8 with pituitary macroadenoma and chiasmatic compression (3 male, 5 female). The corresponding mean ages were 72.8 years (range 58-90) and 60.7 years (range 43-73). All participants underwent complete ophthalmological examination, spectral domain OCT and OCTA, and visual field testing. Clinical, imaging, and visual field results were compared between the groups. RESULTS: On OCT analysis, the glaucoma group had relatively lower peripapillary retinal nerve fiber layer (RNFL) thickness (65.79 ± 15.46, 86.0 ± 11.37, respectively, P = .002) and lower rim area (1.00 ± 0.22 mm2 and 1.2 ± 0.15 mm2, respectively, P = .005). On OCTA, peripapillary vessel density was significantly lower in all quadrants in the glaucoma group. The significance of these between-group differences was maintained when patients were stratified by visual field mean deviation. CONCLUSIONS: This is the first comparative analysis of optic disc morphology between glaucoma and pituitary macroadenoma using combined OCT and OCTA. The results yielded lower peripapillary RNFL thickness, lower rim area, and lower peripapillary vessel density in the glaucoma group. These parameters may aid in the initial differentiation between these two optic neuropathies.

Peripheral Exudative Hemorrhagic Chorioretinopathy with and without treatment-Clinical and multimodal imaging characteristics and prognosis.

PURPOSE: To describe clinical and imaging characteristics of patients with Peripheral Exudative Hemorrhagic Chorioretinopathy (PEHCR), prognosis and treatment response. METHODS: In this retrospective cohort study medical records of patients diagnosed with PEHCR in a tertiary medical center between 2008 and 2018 were reviewed. Collected data included demographics, medical history, ophthalmologic examination and multi-modal imaging including fundus autofluorescence, optical coherence tomography (OCT), ultrasound (US), fluorescein angiography and indocyanine green angiography when available. Bevacizumab treatment results were analyzed when applied. RESULTS: 35 eyes of 32 patients were included, with a female predominance (56.25%) and an average age of 79.0±9.87 years at presentation. Most common OCT and US findings were subretinal mass (68.75%), pigment epithelial detachment (30.00%) and atrophic changes (21.86%). Median follow-up period was 18.00 months (range 0-102). Visual acuity (VA) remained stable (39.29%) or improved (25.00%) in most cases available for follow-up. Treatment with intravitreal bevacizumab induced a statistically significant clinical resolution in 88.89% of eyes available for follow-up (8/9 eyes) (p = 0.02). CONCLUSIONS: PEHCR is presented with high clinical variability and generally good prognosis. This is the first publication demonstrating a statistically significant clinical resolution of disease following intravitreal bevacizumab injections.

Periodic Eye Examinations among Ophthalmologists: Attitudes, Performance, and Barriers for Compliance.

BACKGROUND: Preventive eye care is a preferred practice that includes recommended regular eye examinations, which is not always followed. OBJECTIVE: This study examined attitudes of ophthalmologists toward routine eye examinations, analyzed compliance with their own eye examinations, and described reasons for non-compliance. METHODS: This was a cross-sectional study involving an online survey, sent to all members of the Israeli Ophthalmological Society (IOS) asking their personal opinions concerning routine eye care, self-performance of these tests, and reasons for non-compliance. RESULTS: A total of 243 responses were received (59% males, mean age 52 years) representing 40% of IOS members. 98% of respondents think that adults should be routinely screened for eye diseases, most commonly annually (52%) or every two years (36%); however, only 55% of ophthalmologists reported having themselves a routine eye check in the past 3 years, which is significantly lower than their spouse (68%, P = 0.003). Recommendations for routine eye examinations were always higher than their actual performance regardless of the responding ophthalmologists' gender, age or country of birth. Furthermore, female gender was found to be a negative predictor of having these examinations. Pupil dilation was performed in 38% of ophthalmologists' testing, even though 80% of them think it is necessary for a complete examination. 'Lack of time' (35%) and 'forgetfulness' (31%) were the main reasons provided by ophthalmologists as an explanation for not having regular eye testing. CONCLUSIONS: Ophthalmologists typically recognize the importance of preventive eye care, recommending periodic eye examinations for their patients; however, self-performance of these evaluations by the ophthalmologists themselves is much lower.

Ophthalmologists and WhatsApp: Teleophthalmology is already here.

PURPOSE: To estimate the extent of WhatsApp utilization using text and media messages for inter-physician consultations among ophthalmologists (residents and specialists) at various clinical settings and its perceived benefits for ophthalmologists and their patients. We also aimed to detect obstacles that concern ophthalmologists when using WhatsApp as a consultation platform. METHODS: This was a cross-sectional study using a self-administered survey through Google Forms, which was sent to 660 practicing ophthalmologists during April to May 2020. RESULTS: One hundred and ninety-two ophthalmologists completed the questionnaire, 151 of which (78.6%) were specialists and 41 (21.4%) were residents. Most ophthalmologists reported using WhatsApp at least once a day for both personal and professional use. Residents reported lower rates of contacting patients using WhatsApp than specialists (1.51 ± 0.98 vs 2.72 ± 1.32, p < 0.001). Respondents reported WhatsApp consultations frequently replaced referrals of patients to other physicians, with a median of once a week. 97.8% of residents and 91.4% of specialists reported the ability to share media is a major advantage of WhatsApp over other medias, followed by rapid responses for consultations. CONCLUSION: Many ophthalmologists already use WhatsApp as a tool for professional consultations with other providers, mainly thanks to its simplicity and wide availability. Residents use it more frequently than specialists, and ranked it higher when asked how much WhatsApp has improved the clinical setting. Policy makers should address concerns brought up by physicians, such as documentation in medical records and proper compensation for consulting ophthalmologists during and after work hours.

Incidence of non-glaucomatous ocular disease in patients with asymmetric optic disc cupping.

PURPOSE: To evaluate the incidence of non-glaucomatous ocular disease in patients with asymmetric optic disc cupping. METHODS: A retrospective case series, including consecutive patients with cup-to-disc ratio (CDR) asymmetry greater than 0.2. All patients underwent a complete neuro-ophthalmological examination, automated perimetry with the Humphrey 24-2 visual fields program. Retinal nerve fibre layer thickness was measured by optical coherence tomography (OCT). The results of neuroimaging, macular OCT and blood tests were recorded as well. Patients were assigned a diagnosis of glaucomatous optic neuropathy (GON) or non-glaucomatous disease (NGD). The main outcome measure was the rate of non-glaucomatous ocular disease. RESULTS: A total of 120 (67 males) patients with a mean age of 71.1 ± 12.5 years met the inclusion criteria and were included in this study. The mean asymmetry in CDR between the eyes was 0.3 ± 0.13 (range, 0.2-0.9). Twenty patients (16.6%) had a visual field defect not typical for glaucoma and positive relative afferent pupillary defect was found in 24 patients (20%). Six patients were found to have newly diagnosed non-glaucomatous ocular disease: maculopathy in three patients, retinopathy in one patient and traumatic optic neuropathy in two patients. Patients with NGD were significantly younger than the patients with GON (59.8 ± 23.3 vs. 71.3 ± 11.5 years, P = 0.001). Optic disc pallor was found in 4/93 patients with glaucoma compared to 3/6 with newly diagnosed non-glaucomatous disease (4.7% vs. 50.0%, P = 0.03). CONCLUSIONS: Asymmetric optic disc cupping can be associated with non-glaucomatous disease and may warrant neuro-ophthalmological evaluation, especially in younger patients or those with optic disc pallor.

Surgical Outcomes of Ahmed Glaucoma Valve Implantation Without Plate Sutures: A 10-Year Retrospective Study.

PRCIS: Ahmed glaucoma valve (AGV) implantation without plate fixation resulted in high rates of complications related to plate or tube movement. PURPOSE: Scleral suturing of the plate of AGV is associated with technical difficulty and potential complications. This study summarizes the surgical outcomes of 10 years of experience with AGV implantation without suture plate fixation. METHODS: The medical records of all glaucoma patients who underwent AGV implantation surgery without plate fixation between 2009 and 2019 at the Sheba Medical Center (Tel Hashomer, Israel) were retrospectively reviewed. Clinical data on intraoperative and postoperative complications, best-corrected visual acuity, intraocular pressure, and number of intraocular pressure-lowering medications were retrieved. RESULTS: Included were 95 eyes of 95 patients (53 men, 42 women; mean age, 54.9±17.5 y). The mean follow-up was 687±673 days. In total, 37 patients (37/95, 38.%) had AGV-related complications, of whom 28 (29.5%) required additional intervention. Women had a significantly higher rate of complications than men (21/42, 50% vs. 16/53, 30.2%, respectively, P=0.049). The 2 most common complications were AGV migration in 13 eyes (13.7%) and tube exposure/AGV extrusion in 9 eyes (9.5%). AGV was removed in 10 cases. CONCLUSIONS: In this cohort, omitting suture AGV plate fixation resulted in high rates of complications related to plate or tube movement, the need for further intervention, and AGV removal. Therefore, we cannot recommend this surgical technique.

A novel EyePhone© App for improving adherence to glaucoma therapy.

PURPOSE: Despite advances in glaucoma treatment options, patient adherence and compliance remain very low. The EyePhone© App is a free non-commercial reminder application designed specifically for the needs of glaucoma patients. In this study, we evaluated its usefulness in improving adherence to medical treatment among glaucoma patients. METHODS: This is a prospective multicenter interventional study. Glaucoma patients were recruited from a tertiary center and a large community glaucoma service center. After a short explanation, the EyePhone© App was installed on their smartphone device, and the notifications for the current medical treatment were entered. After enrollment and at 1-month follow-up, subjects completed the Morisky Medication Adherence Scale (MMAS-8) and the Quality of Life and Glaucoma 17-item (GlauQOL-17) questionnaires for evaluation of adherence and QOL, respectively. RESULTS: In the study, 133 patients (71 men and 62 women) aged 62±15.5 years and using 2.0±0.9 IOP-lowering drugs participated. The proportion of highly adherent subjects improved from 29.3% (39/133) at baseline to 42.1% (56/133) at follow-up (P < 0.001), and the proportion of poorly adherent subjects decreased from 29.3 (39/133) to 20.3% (27/133) at follow-up (P = 0.012). QOL also improved, as evidenced by a significant increase in the GlauQOL-17 score (P < 0.05). In a subgroup of patients for whom IOP measurements were available, IOP reduced by 0.92 mmHg (P = 0.069). CONCLUSIONS: Significant improvements in glaucoma adherence and QOL were achieved among poorly adherent glaucoma patients after 1 month of using the EyePhone© App.

Cost containment by peer prior authorization program for second line treatment in patients with retinal disease.

BACKGROUND: High and increasing drug prices have prompted the establishment of a broad range of cost-containment treatment policies in health systems globally. In 2012, the supplemental insurance program of a large Israeli health maintenance organization (Clalit Health Services) introduced a prior authorization process for second-line use of ranibizumab in patients with retinal disease for whom treatment with bevacizumab proved to be ineffective. A Clalit steering committee established authorization criteria based on cost and periodically updated clinical considerations, while a team of ophthalmic specialists evaluated their colleagues' individual patient subsidization requests, based on the funding criteria. The objectives of this study were to detail this unique authorization process and study its effectiveness in limiting unwarranted spending, while allowing for a smooth transition to a second-line more expensive drug when needed. METHODS: A retrospective cohort study including all applications for a first or ongoing treatment with ranibizumab, for one or both eyes, received during March 1, 2012 - December 31, 2015. The key parameters examined were percentages of requests from patients treated by first line treatment bevacizumab, requests approved, reapplications, and results. Requests studied include reapplications and requests for treatment continuation. RESULTS: During the study period, Clalit affiliated ophthalmologists' submitted 16,778 funding applications for intravitreal ranibizumab treatment on behalf of 5642 patients who applied for approximately three applications. An efficient sentinel effect was achieved, resulting in only 31% of patients treated with bevacizumab applying for treatment, while maintaining extremely high accessibility to second line treatment with almost 95% of requests being approved. CONCLUSIONS: The data presented shows a low request rate for funding with a high approval rate, proving this peer reviewed report-based authorization process successfully achieved a sentinel effect while controlling cost. We suggest this innovative model be considered in similar decisions processes.

Diagnosis of Pseudoexfoliation Syndrome in Pseudophakic Patients.

OBJECTIVE: The aim of this study was to evaluate the sensitivity and specificity of pseudoexfoliation syndrome diagnosis in pseudophakic patients and potential means of improving it. METHODS: This prospective, nonrandomized study comprised 41 consecutive patients (41 eyes) scheduled for cataract surgery at a tertiary medical center during 2016 and 2017. Preoperatively, all patients underwent a detailed slit-lamp examination, including gonioscopic assessment of the iridocorneal angle. The examination was performed by a glaucoma specialist who completed an assessment form documenting the presence/absence of clinical signs of pseudoexfoliation syndrome. It was repeated 1-2 weeks postoperatively by a second, masked, glaucoma specialist. RESULTS: Sixteen patients (39.0%) were diagnosed with pseudoex-foliation syndrome preoperatively. The diagnosis was confirmed postoperatively in 11/16 patients (68.8% sensitivity) and in an additional patient not diagnosed preoperatively (96% specificity). The ability to diagnose pseudoexfoliation syndrome postoperatively was significantly worse than preoperatively (Z = 12.161, p < 0.0001). Pupillary border deposits (75% of cases) and the Sampaolesi line (83.3%) were the cornerstones of the postoperative diagnosis; anterior capsular deposits were evident in only 41.6% of cases diagnosed postoperatively (31.3% of the originally diagnosed cases). CONCLUSIONS: Underdiagnosis of pseudoexfoliation syndrome is common in pseudophakic patients and may have significant implications for future management. Careful attention to pupillary border anatomy and meticulous gonioscopic assessment of the iridocorneal angle are essential for accurate diagnosis. Preoperative documentation of pseudoexfoliation syndrome could help prevent this diagnostic pitfall.

Avoiding Diagnostic Lens Fogging During the COVID-19 Era.

Since the advent of COVID-19, the patient's use of a face mask hampers our visibility because there is a marked fogging in our view produced by the warm breath that escapes from the top of the patient's mask and lands on the cooler surface of the lens. This panorama is sometimes so frustrating that we have been forced to ask our patients to remove their facemasks while examined, increasing the risk of being infected. We consider it essential to share this small pearl technique that we can apply in order to avoid fogging during the examination; it is easy, and most importantly, without putting at risk the patient or doctor's health. In our opinion, this is the first material to propose this technique.

Short-term anterior chamber inflammation in phacoemulsification with and without Ex-Press glaucoma implant.

PURPOSE: The aim of this study was to investigate the incidence of clinically significant anterior chamber inflammation in a combined surgery, namely, phacoemulsification and Ex-Press miniature glaucoma device implantation, compared to phacoemulsification alone. METHODS: A retrospective comparative study of a consecutive series of 210 participants above 18 years of age diagnosed with significant cataract and who required glaucoma surgery, namely, Ex-Press miniature glaucoma device implantation or cataract alone in one or both eyes. All were operated on by a single experienced glaucoma surgeon in a single medical center. A total of 231 eyes were included in this study. All cases underwent an uneventful surgery and were examined the day following the surgery for visual acuity, intraocular pressure, and signs of excessive anterior chamber inflammation (Standardization of Uveitis Nomenclature grading ⩾ 3). RESULTS: The combined group included 55 eyes of 51 patients, of whom 15 (27.3%) demonstrated excessive anterior chamber inflammation. The phacoemulsification group included 176 eyes of 159 patients, of whom 12 (6.7%) demonstrated excessive anterior chamber inflammation. Visual acuity and intraocular pressure measurements showed no statistically significant difference between the two groups. CONCLUSION: The Ex-Press glaucoma device is efficient, safe, and known for its inert nature. However, combination of this procedure with phacoemulsification surgery might result in a condition encouraging excessive inflammation, which eventually could lead to excessive anterior chamber inflammations if not treated vigorously. Emphasizing and recognizing the risks, especially in glaucoma patients, is important.

Optical Coherence Tomography May Help Distinguish Glaucoma from Suprasellar Tumor-Associated Optic Disc.

PURPOSE: This study aimed to differentiate patients with bilateral disc cupping associated with suprasellar tumor from patients with open-angle glaucoma by analyzing differences in optical coherence tomography (OCT) of the optic nerve. METHODS: In this retrospective cross-sectional study, we collected data from the eyes of 25 patients with suprasellar craniopharyngioma or pituitary macroadenomas (group 1) and 35 patients with primary open-angle glaucoma (POAG) (group 2), seen between 2001 and 2015, all with a visual acuity of ≥20/40, for whom Stratus Time-Domain (TD) optic nerve OCT scans were available. The main outcome measures were the retinal nerve fiber layer (RNFL) thickness, disc area, cup volume, cup/disc ratio, and rim area. RESULTS: A total of 31 patients met the inclusion criteria and were included in the study: 16 with suprasellar tumors and 15 with POAG. Both groups were similar in terms of gender and age (P > 0.05). The glaucoma group had a borderline greater total RNFL thickness (74.2 µm versus 62.8 µm, P=0.07), disc area (2.70 mm2 versus 2.16 mm2, P=0.004), and cup volume (0.20 mm3 versus 0.08 mm3, P=0.02). In multivariate, glaucoma was associated with increased total RNFL thickness (OR = 1.116 per µm, P=0.008), increased disc area (OR = 2.402 per 100 µm2, P=0.002), and decreased rim area (OR = 0.272 per 100 µm2, P=0.011). Of these, the parameter with the greatest AUC was the disc area (AUC = 0.79). Using the Youden index, the optimal cut-off point identified for stratification was a disc area greater than 2.33 µm2. CONCLUSIONS: In patients with bilateral disc cupping, a decreased total RNFL thickness and smaller disc area seem to be associated with suprasellar tumors (when compared with open-angle glaucoma). These findings may aid in early diagnosis of cupping from suprasellar tumors, before compressive visual loss occurs.

Prostaglandin analogue drops for the treatment of soft tissue expansion and exophthalmos in patients with inactive thyroid eye disease.

OBJECTIVE: Thyroid eye disease (TED) is characterized by an inflammatory response leading to soft tissue expansion within the bony orbit, which may cause exophthalmos. Studies of glaucoma patients reported periorbital fat atrophy after treatment with prostaglandin analogue drops. We hypothesize that owing to this side effect, prostaglandin analogue drops may benefit patients with TED-induced exophthalmos. DESIGN: Interventional prospective pilot study. PARTICIPANTS: Five adults with inactive TED and exophthalmos treated with a single daily drop of bimatoprost to both eyes for 6 months. METHODS: The effect of treatment was evaluated by clinical examinations, Hertel exophthalmometry, marginal reflex distance (MRD), and comparison of digital photographs from before and after treatment by 3 masked oculoplastic surgeons. Patients' subjective satisfaction was recorded as well. RESULTS: Hertel exophthalmometry showed an improvement in exophthalmos after treatment in 3 patients and no change in 2. Both MRD1 and MRD2 increased (for MRD2 p = 0.007). Two observers correctly identified the photograph taken after treatment in 4 patients, and the third observer correctly identified 2 patients and was indecisive about the others. Four patients reported an improvement in their appearance, although additional eyelid retraction was observed. Adverse effects were minimal. CONCLUSION: Topical prostaglandin analogue treatment of TED-associated exophthalmos appears safe. Although this pilot study was statistically underpowered to show positive results, our findings suggest a treatment-related reduction in periorbital fat volume in most cases and a subjective improvement in appearance. These findings have potential implications for the treatment of exophthalmos in the clinical setting, but more research is required.

[OPHTHALMOLOGY - FACING THE FUTURE].

INTRODUCTION: This special issue of HaRefuah is dedicated to Ophthalmology facing the future. This dynamic and forever innovative field of medicine is in a constant state of development in all its sub-specialties. In ophthalmology we often witness immediate rewarding results of treatment and surgery, having a huge impact on one of the most important senses, namely improving sight, stopping deterioration and preventing blindness. We are inviting the readers for an overview of some of the research and special cases, as well as some reviews of the hottest topics in ophthalmology.