Efficacy of anti-VEGF monotherapy versus anti-VEGF therapy with subthreshold micropulse laser (SML) in the management of diabetic macular oedema (DMO): a systematic review and meta-analysis.

BACKGROUND: Intravitreal injection anti-vascular endothelial growth factor (IVI anti-VEGF) therapy serves as the primary treatment for centre involving diabetic macular oedema (DMO). Conventional laser therapy (CLT) adjunct has proven beneficial; however, it is not widely used due to significant risks of retinal scarring. Subthreshold micropulse laser (SML) therapy has, however, emerged as a comparable alternative to combination therapy, offering a distinct advantage by mitigating the risk of retinal scarring. METHODS: A search of six databases was conducted. A meta-analysis of mean differences was performed including subgroup analyses where appropriate. Primary outcome was the number of injections at 12-14 months; secondary outcomes were changes in central macular thickness (CMT) and best corrected visual acuity (BCVA) at 6-8 months and 12-14 months. RESULTS: A total of ten papers including six randomised clinical trials and four retrospective clinical studies were included in our study, capturing 563 eyes of 478 patients. Overall, the risk of bias was moderate for these studies. Significantly fewer anti-VEGF therapy injections were administered in the combination therapy versus anti-VEGF monotherapy patients at 12-14 months who had poor visual acuity (6/18 Snellen or worse) at baseline, mean difference - 2.25 (95% CI; - 3.35, - 1.15; p < 0.05). Combination therapy was not associated with significantly fewer intravitreal injections in patients with a higher visual acuity (6/15 Snellen or better) at baseline. Our analysis also showed significant improvements to both BCVA and CMT were reached at 6 - 8 month post-baseline at the 95% confidence intervals: - 1.13 (- 2.09, - 0.16) and - 4.04 (- 7.59, - 0.50). These improvements remained statistically significant at 12-14 months: - 0.94 (- 1.67, - 0.20) and - 1.92 (- 3.52, - 0.32) respectively with combination therapy. CONCLUSION: Our findings demonstrate that combination therapy (SML + IVI anti-VEGF) is associated with fewer intravitreal injections. We report a better BCVA and a reduction in CMT at 6 and 12 months from baseline with combination treatment compared to the IVI anti-VEGF monotherapy comparator. SML is a proven non-scarring cost-effective therapy for DMO that should be readily available in the medical retinal therapy as it may reduce the burden of care.

Concentric Reversible Visual Field Loss, Nyctalopia, and Dyschromatopsia with Ezetimibe Therapy.

This is a case of ezetimibe-induced concentric field loss, dyschromatopsia, and nyctalopia in a patient with no prior history of retinal dystrophy or drug hypersensitivity. A 55-year-old Caucasian woman presents with a 1-year history of increasing concentric visual field loss, nyctalopia, photophobia, and colour vision impairment. These symptoms correlated with the commencement of ezetimibe therapy 10 mg daily for hypercholesterolaemia. She demonstrated repeatable bilateral visual field constriction on 30-2 Humphrey visual filed testing and colour vision impairment on Ishihara plates (OD: 1/17, OS: 1/17). Biochemical and radiological screening for carcinoma-associated retinopathy was unremarkable. A working diagnosis of drug-induced rod-cone dysfunction was made. Her visual symptoms and field changes completely resolved 3 months after cessation of ezetimibe therapy. This case suggests that ezetimibe is a potential cause of rod-cone dysfunction and should be considered as a differential in patients with new unexplained visual symptoms.

Quantitative lacrimal scintigraphy in the assessment of epiphora.

The transit of Tc-99m pertechnetate through 122 lacrimal drainage systems was quantified. Systems were categorized as having presac, preduct, intraduct, or no delay. Scintigraphy indicated an obstruction in 81.3% of eyes with epiphora. Of the 18 eyes in whom only scintigraphy revealed an obstruction, all 3 who underwent surgery experienced symptom relief. In patients presenting with unilateral epiphora the mean canthus half-time (12.9 vs. 7.2 minutes), time-to-peak activity at the sac (11.6 vs. 3.1 minute), and sac half-time (19.0 vs. 10.3 minutes) were significantly prolonged in the symptomatic eye. Similarly, the sac-to-canthus (0.32 vs. 0.72), duct-to-canthus (0.32 vs. 0.99), and duct-to-sac ratios (0.48 vs. 0.79) of peak activity were all significantly reduced in the symptomatic eye. When compared with "no delay," "presac," "preduct," and "intraduct" delay were significantly associated with attenuated clearance times or reduced ratios of peak activity corresponding to the level of obstruction. We conclude that there is a significant association between symptomatic epiphora and quantitative variables at the canthus and sac in lacrimal scintigraphy. Quantitative variables help locate the level of an obstruction.

Merkel cell carcinoma: assessing the effect of wide local excision, lymph node dissection, and radiotherapy on recurrence and survival in early-stage disease--results from a review of 82 consecutive cases diagnosed between 1992 and 2004.

BACKGROUND: Wide surgical excision, lymph node dissection, and radiotherapy have been used with varying efficacy in the management of early-stage Merkel cell carcinoma. METHODS: Records of 82 patients with early-stage Merkel cell carcinoma between 1992 and 2004 were reviewed. RESULTS: Forty-two patients developed a recurrence, and 44 died during the study period. Twenty-nine patients presented with regional lymph node disease, which was independently associated with diminished survival (hazard ratio [HR], 4.08; 95% confidence interval [CI], 1.55-10.75; P = .005). Lymphadenectomy was independently associated with prolonged disease-free survival (median, 28.5 vs. 11.8 months; HR, .46; 95% CI, .22-.94; P = .034) but not overall survival (P = .25). Margin-negative excision of the primary tumor (60 of 73) was not significantly associated with either prolonged disease-free survival (median, 16 vs. 14 months) or overall survival (median, 54 vs. 34 months). Forty-eight patients received radiotherapy: 36 to the primary site and 31 to the regional lymph nodes. Radiotherapy to both sites was associated with a longer median time to first recurrence (primary site, 24.2 vs. 11.8 months; regional lymph nodes, 46.2 vs. 11.3 months) and survival (primary site, 53.9 vs. 45.7 months; regional lymph nodes, 103.1 vs. 34.2 months). Administration of any radiotherapy was significantly associated with a prolonged time to first recurrence (HR, .39; 95% CI, .20-.75; P = .004) and survival (HR, .39; 95% CI, .18-.82; P = .013) on the Cox regression multivariate analyses. CONCLUSIONS: Adjuvant radiotherapy to the primary site after surgical excision is recommended in early-stage disease. Involved regional lymph nodes should be treated with radiotherapy with or without lymphadenectomy.

Intraocular lens power in bilateral cataract surgery: whether adjusting for error of predicted refraction in the first eye improves prediction in the second eye.

PURPOSE: To assess whether the retrospectively calculated intraocular lens (IOL) position value in the first eye reduces the error of predicted refraction in the second. SETTING: Prince of Wales Hospital, Sydney, Australia. METHODS: One hundred twenty-one consecutive patients who had bilateral cataract surgery with the same IOL (SI-30NB, Advanced Medical Optics) were identified. The case-derived A-constant in the first eye was calculated from the postoperative refraction. This value was used to calculate the adjusted error of predicted refraction in the second eye and compared against the unadjusted error in that eye (calculated using manufacturer's A-constant). RESULTS: Axial length (r = 0.97), corneal power (r = 0.97), and IOL power (r = 0.90) were strongly correlated between eyes with no statistically significant mean interocular difference. Although there was no significant interocular difference in the mean error of predicted refraction (SRK/T), there was only a moderate correlation between eyes (r = 0.40). Using the axial length vergence formula, the mean adjusted error of predicted refraction in the second eye (-0.66 diopter [D]) was significantly larger than the mean unadjusted error (-0.47 D) (P = .029). The standard deviation of the adjusted error of predicted refraction (SRK/T) in the second eye (0.85 D) was greater than the standard deviation of the unadjusted error (0.79). Similarly, the adjusted mean absolute error of predicted refraction (0.65 D) was greater than the unadjusted error (0.63 D). CONCLUSION: Adjusting the IOL power in the second eye by the amount of overprediction or underprediction in the first eye did not improve prediction accuracy because the error of predicted refraction varied independently between the 2 eyes of an individual.

Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists.

This retrospective study was conducted to assess and compare the diagnostic accuracy between referring general practitioners and dermatologists with regard to skin conditions. Six hundred and fifty-six consecutive general practitioner referrals to a private dermatology practice and a dermatology outpatient department were assessed. The concordance rate in diagnoses from a wide spectrum of dermatological diseases was compared between general practitioners and dermatologists. Referring general practitioners agreed with dermatologists' clinical diagnosis and histology (when available) in 42% of cases. The concordance between general practitioners and dermatologists in the setting of non-biopsied cases is 45%. One hundred and fifty-one of 656 (23%) conditions had histological confirmation. Overall, general practitioners agreed with the histological diagnosis in 24% of cases and dermatologists agreed with the histological diagnosis in 77% of cases.