The Association Between Retinal Thickness Fluctuations and Visual Outcomes Under Anti-VEGF Therapy: A Systematic Review and Meta-Analysis.

INTRODUCTION: To examine the association between retinal thickness (RT) fluctuations and best-corrected visual acuity (BCVA) in eyes with neovascular AMD, macular edema secondary to RVO, and DME treated with anti-VEGF therapy. METHODS: A systematic search of Ovid MEDLINE, EMBASE, and the Cochrane Library was performed from January 2006 to March 2024. Studies comparing visual or anatomic outcomes of patients treated with anti-VEGF therapy, stratified by magnitudes of RT fluctuation, were included. ROBINS-I and Cochrane RoB 2 tools were used to assess risk of bias, and certainty of evidence was evaluated with GRADE criteria. Meta-analysis was performed with a random effects model. Primary outcomes were final BCVA and change in BCVA relative to baseline. RESULTS: 15725 articles were screened; 15 studies were identified in the systematic review and 5 studies were included in the meta-analysis. Final ETDRS VA was significantly worse in eyes with the highest level of RT fluctuation (weighted mean difference (WMD) = 7.86 letters; 95% CI, 4.97, 10.74; p < 0.00001; I² = 81%; 3136 eyes). RT at last observation was significantly greater in eyes with high RT fluctuations (WMD = -27.35 µm; 95% CI, -0.04, 54.75; p = 0.05; I2 = 88%; 962 eyes). CONCLUSIONS: Final visual outcome is associated with magnitude of RT fluctuation over the course of therapy. It is unclear whether minimizing RT fluctuations would help to optimize visual outcomes in patients treated with anti-VEGF therapy. These findings are limited by a small set of studies, risk of bias, and considerable heterogeneity.

Physical and Psychosocial Challenges as Predictors of Vision Difficulty in Children: A Nationally Representative Survey Analysis.

PURPOSE: To elicit associations between vision difficulties and physical or psychosocial challenges in children in the United States. METHODS: Children aged 2-17 years old from the 2021 National Health Interview Survey with data pertaining to vision difficulty were included in our retrospective, population-based analysis. Our primary aim was investigating physical and psychosocial challenges as predictors of vision difficulty. Logistic regression models were performed on Stata version 17.0 (StataCorp LLC, College Station, Texas). Analyses were accompanied by an odds ratio (OR) and 95% confidence interval (CI). RESULTS: A total of 7,373 children had data pertaining to their level of vision difficulty and were included in our sample. In our multivariable analysis, children with a good/fair (OR = 1.84, 95% CI = [1.31, 2.60], p < 0.01), or poor (OR = 5.08, 95% CI = [1.61, 16.04], p < 0.01) general health status had higher odds of vision difficulty relative to children with an excellent/very good health status. Furthermore, children with difficulties hearing (OR = 8.67, 95% CI = [5.25, 14.31], p < 0.01), communicating (OR = 1.96, 95% CI = [1.18, 3.25], p < 0.01), learning (OR = 1.93, 95% CI = [1.27, 2.93], p < 0.01), and making friends (OR = 1.94, 95% CI = [1.12, 3.36], p = 0.02) had higher odds of vision difficulty. Nonetheless, the following factors were only predictors of vision difficulty in our univariable analysis: requiring equipment for mobility (p < 0.01), experiencing anxiety (p < 0.01), and experiencing depression (p < 0.01). CONCLUSION: Several factors pertaining to physical and psychosocial challenges in children are associated with vision difficulty. Future research should further explore potential causal links between vision difficulty and physical or psychosocial factors to aid in coordinating public health efforts dedicated to vision health equity.

International Classification System for Ocular Complications of Anti-Vascular Endothelial Growth Factor Agents in Clinical Trials.

OBJECTIVE: Complications associated with intravitreal anti-vascular endothelial growth factor (VEGF) therapies are inconsistently reported in the literature, thus limiting an accurate evaluation and comparison of safety between studies. This study aimed to develop a standardized classification system for anti-VEGF ocular complications using the Delphi consensus process. DESIGN: Systematic review and Delphi consensus process. PARTICIPANTS: 25 international retinal specialists participated in the Delphi consensus survey. METHODS: A systematic literature search was conducted to identify complications of intravitreal anti-VEGF agent administration based on randomized controlled trials (RCTs) of anti-VEGF therapy. A comprehensive list of complications was derived from these studies, and this list was subjected to iterative Delphi consensus surveys involving international retinal specialists that voted on inclusion, exclusion, rephrasing, and addition of complications. As well, surveys determined specifiers for the selected complications. This iterative process helped refine the final classification system. MAIN OUTCOME MEASURES: The proportion of retinal specialists who choose to include or exclude complications associated with anti-VEGF administration. RESULTS: After screening 18,229 articles, 130 complications were initially categorized from 145 included RCTs. Participant consensus via the Delphi method resulted in the inclusion of 91 (70%) complications after three rounds. After incorporating further modifications made based on participant suggestions, such as rewording certain phrases and combining similar terms, 24 redundant complications were removed, leaving a total of 67 (52%) complications in the final list. A total of 14 (11%) complications met exclusion thresholds and were eliminated by participants across both rounds. All other remaining complications not meeting inclusion or exclusion thresholds were also excluded from the final classification system after the Delphi process terminated. In addition, 47 out of 75 (63%) proposed complication specifiers were included based on participant agreement. CONCLUSION: Using the Delphi consensus process, a comprehensive, standardized classification system consisting of 67 ocular complications and 47 unique specifiers was established for intravitreal anti-VEGF agents in clinical trials. The adoption of this system in future trials could improve consistency and quality of adverse event reporting, potentially facilitating more accurate risk-benefit analyses.

Epiretinal Membrane Formation following Rhegmatogenous Retinal Detachment Repair: A Retrospective Cohort Study.

INTRODUCTION: This study aimed to investigate the incidence of and risk factors for epiretinal membrane (ERM) formation following primary rhegmatogenous retinal detachment (RRD) repair. METHODS: This comparative, retrospective, single-center cohort study included eyes with primary RRD treated between 2011 and 2023 at Massachusetts Eye and Ear, Boston, Massachusetts, with pars plana vitrectomy (PPV), scleral buckle (SB), PPV+SB, or pneumatic retinopexy (PnR). Demographic, clinical, and surgical parameters were collected from medical records. The primary outcome was the risk of ERM formation, while the secondary outcome was the risk of ERM requiring surgery. Univariable and multivariable Cox regression were performed, and a hazard ratio (HR) and 95% confidence interval (95% CI) were reported. RESULTS: Overall, 394 eyes were included. The mean age was 58.49 ± 12.8 years, and most patients were male. There was a significantly lower risk of ERM formation following SB compared to PPV in the univariable analysis (HR = 0.2, 95% CI = 0.08-0.60, p = 0.003); however, there was no significant association between treatment modality and ERM formation on multivariable Cox regression controlling for confounding factors (p = 0.24). ERM formation was found more commonly in patients who were older (HR = 1.0 per 1 year increase in age, 95% CI = 1.01-1.04, p = 0.001), those with worse baseline visual acuity (HR = 1.3, 95% CI = 1.09-1.71, p = 0.008), and those with macula-off RRDs (HR = 2.1, 95% CI = 1.41-3.32, p < 0.001). CONCLUSION: Surgical modality does not have a significant impact on the risk of ERM following retinal detachment repair. However, age, baseline visual acuity, and macular status are important predictors of ERM formation after RRD repair.

Pars Plana Vitrectomy With Silicone Oil or Gas Tamponade for Uncomplicated Retinal Detachment: A Systematic Review and Meta-Analysis.

PURPOSE: To compare the efficacy and safety of pars plana vitrectomy (PPV) with silicone oil compared to gas tamponade for uncomplicated rhegmatogenous retinal detachment (RRD). DESIGN: Systematic review and meta-analysis. METHODS: A systematic literature search was conducted on Ovid MEDLINE, Embase, and the Cochrane Library from January 2000 to September 2023 for comparative studies evaluating the efficacy and safety of PPV with either silicone oil or gas tamponade in the setting of uncomplicated RRD. Our primary outcome was best-corrected visual acuity at the last study observation. Secondary outcomes included the rates of retinal reattachment, retinal thickness, and the incidence of adverse events. We performed a meta-analysis using a random-effects model. RESULTS: Nine observational studies reporting on 491 RRD eyes were included. The mean best-corrected visual acuity at the last study observation was significantly better in the gas tamponade group than in the silicone oil group (weighted mean difference [WMD] = 0.17 logMAR, 95% confidence interval [CI] = [0.06, 0.27], P = .002). Rates of primary retinal reattachment were similar between the silicone oil and gas tamponade groups (P = .89). The ganglion cell layer was significantly thinner in the silicone oil group compared to the gas tamponade group (WMD =-3.70 µm, 95% CI = [-5.87, -1.53, P = .0008), as was the inner plexiform layer (WMD = -2.45, 95% CI = [-4.50, -0.40], P = .02) and outer nuclear layer (WMD = -11.74 µm, 95% CI = [-18.39, -5.10], P = .0005). CONCLUSIONS: PPV with gas tamponade was associated with better functional outcomes compared to PPV with silicone oil, although both tamponades yielded comparable primary reattachment rates. The absence of randomized trials and the potential for selection bias underscore the importance of further investigation in diverse patient populations.

Google Gemini and Bard artificial intelligence chatbot performance in ophthalmology knowledge assessment.

PURPOSE: With the popularization of ChatGPT (Open AI, San Francisco, California, United States) in recent months, understanding the potential of artificial intelligence (AI) chatbots in a medical context is important. Our study aims to evaluate Google Gemini and Bard's (Google, Mountain View, California, United States) knowledge in ophthalmology. METHODS: In this study, we evaluated Google Gemini and Bard's performance on EyeQuiz, a platform containing ophthalmology board certification examination practice questions, when used from the United States (US). Accuracy, response length, response time, and provision of explanations were evaluated. Subspecialty-specific performance was noted. A secondary analysis was conducted using Bard from Vietnam, and Gemini from Vietnam, Brazil, and the Netherlands. RESULTS: Overall, Google Gemini and Bard both had accuracies of 71% across 150 text-based multiple-choice questions. The secondary analysis revealed an accuracy of 67% using Bard from Vietnam, with 32 questions (21%) answered differently than when using Bard from the US. Moreover, the Vietnam version of Gemini achieved an accuracy of 74%, with 23 (15%) answered differently than the US version of Gemini. While the Brazil (68%) and Netherlands (65%) versions of Gemini performed slightly worse than the US version, differences in performance across the various country-specific versions of Bard and Gemini were not statistically significant. CONCLUSION: Google Gemini and Bard had an acceptable performance in responding to ophthalmology board examination practice questions. Subtle variability was noted in the performance of the chatbots across different countries. The chatbots also tended to provide a confident explanation even when providing an incorrect answer.

Preoperative Visual Acuity Thresholds in Pars Plana Vitrectomy for Epiretinal Membrane: A Systematic Review.

BACKGROUND AND OBJECTIVE: This review consolidates findings from studies that used a preoperative visual acuity (VA) threshold as an indication for epiretinal membrane (ERM) surgery. METHODS: The literature was systematically searched using Ovid MEDLINE, EMBASE, and Cochrane Library from January 2000 to October 2022 to select studies reporting on pars plana vitrectomy (PPV) for ERM that used a preoperative VA threshold as an inclusion criterion. Primary outcomes were final best-corrected visual acuity (BCVA) and change in BCVA relative to baseline. Secondary outcomes included risk of intra- and postoperative complications. RESULTS: A total of 639 eyes from seven studies were included. The most liberal preoperative VA threshold was 20/28.5 or worse, whereas the most conservative threshold was worse than 20/60. The mean preoperative BCVA was 0.55 logarithm of the minimum angle of resolution (logMAR) (∼20/70), and the mean postoperative BCVA was 0.35 logMAR (∼20/45). Generally, VA improved relative to baseline, regardless of the preoperative VA threshold. The smallest improvement in VA was observed in a study where the pre-operative VA to consider surgery was liberal (20/30 or worse), whereas the greatest VA improvement was observed in a study that used a conservative preoperative VA threshold (worse than 20/60). CONCLUSIONS: The greatest improvement in BCVA was observed in studies where a conservative pre-operative VA threshold was used. The decision to operate should involve a patient-centered approach with a thorough discussion of the risks and benefits of PPV, regardless of the preoperative VA threshold used. [Ophthalmic Surg Lasers Imaging Retina 2024;55:400-407.].

SURGICAL DRAINAGE METHODS DURING PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT: A Systematic Review and Meta-Analysis.

PURPOSE: To assess efficacy and safety outcomes of subretinal fluid drainage methods during pars plana vitrectomy for rhegmatogenous retinal detachment. METHODS: A systematic search strategy was conducted for studies published between January 2000 and October 2022. Included studies reported on either the safety or efficacy of two or more drainage methods during pars plana vitrectomy for patients with rhegmatogenous retinal detachment. RESULTS: Two randomized and five observational studies consisting of 1,524 eyes were included. Best-corrected visual acuity at the last study observation and primary reattachment rates were similar across groups. A significantly lower risk of epiretinal membrane formation was associated with draining subretinal fluid through preexisting retinal breaks (risk ratio = 0.70, 95% confidence interval = [0.60, 0.83], P = <0.01, I 2 = 0%) or with perfluorocarbon liquid (risk ratios = 0.70, 95% confidence interval = [0.59, 0.83], P = <0.01, I 2 = 0%) compared with posterior retinotomy. The risk of an abnormal foveal contour was significantly greater in perfluorocarbon liquid-treated eyes relative to posterior retinotomy (risk ratios = 1.56, 95% confidence interval = [1.13, 2.17], P = <0.01, I 2 = 0%). CONCLUSION: No significant differences were observed in the final best-corrected visual acuity at the last study observation and primary reattachment rates across different drainage methods. There remains limited information on the topic, so future research is warranted.

ADAPTIVE OPTICS IMAGING IN DIABETIC RETINOPATHY: A Prospective Cohort Study.

PURPOSE: To investigate the correlation between diabetic retinopathy (DR) severity and microscopic retinal and vascular alterations using adaptive optics imaging. METHODS: In this single-center, prospective cohort study, adult participants with healthy eyes or DR underwent adaptive optics imaging. Participants were classified into control/mild nonproliferative DR, moderate/severe nonproliferative DR, and proliferative DR. Adaptive optics imaging using the RTX1 camera was obtained from 48 participants (87 eyes) for photoreceptor data and from 36 participants (62 eyes) for vascular data. RESULTS: Photoreceptor parameters significantly differed between DR groups at 2° and 4° of retinal eccentricity. Wall-to-lumen ratio varied significantly at 2° eccentricity, while other vascular parameters remained nonsignificant. Cone density and dispersion were the strongest predictors for DR severity ( P < 0.001) in multivariable generalized estimating equation modeling, while other vascular parameters remained nonsignificant between DR severity groups. All photoreceptor parameters showed significant correlations with visual acuity overall and across most DR severity groups. CONCLUSION: To date, this is one of the largest studies evaluating the use of adaptive optics imaging in DR. Adaptive optics imaging was demonstrated to differentiate between various levels of disease severity in DR. These results support the potential role in diagnostic and therapeutic microstructural evaluation in research and clinical practice.

Accuracy of an Artificial Intelligence Chatbot's Interpretation of Clinical Ophthalmic Images.

Importance: Ophthalmology is reliant on effective interpretation of multimodal imaging to ensure diagnostic accuracy. The new ability of ChatGPT-4 (OpenAI) to interpret ophthalmic images has not yet been explored. Objective: To evaluate the performance of the novel release of an artificial intelligence chatbot that is capable of processing imaging data. Design, Setting, and Participants: This cross-sectional study used a publicly available dataset of ophthalmic cases from OCTCases, a medical education platform based out of the Department of Ophthalmology and Vision Sciences at the University of Toronto, with accompanying clinical multimodal imaging and multiple-choice questions. Across 137 available cases, 136 contained multiple-choice questions (99%). Exposures: The chatbot answered questions requiring multimodal input from October 16 to October 23, 2023. Main Outcomes and Measures: The primary outcome was the accuracy of the chatbot in answering multiple-choice questions pertaining to image recognition in ophthalmic cases, measured as the proportion of correct responses. χ2 Tests were conducted to compare the proportion of correct responses across different ophthalmic subspecialties. Results: A total of 429 multiple-choice questions from 136 ophthalmic cases and 448 images were included in the analysis. The chatbot answered 299 of multiple-choice questions correctly across all cases (70%). The chatbot's performance was better on retina questions than neuro-ophthalmology questions (77% vs 58%; difference = 18%; 95% CI, 7.5%-29.4%; χ21 = 11.4; P < .001). The chatbot achieved a better performance on nonimage-based questions compared with image-based questions (82% vs 65%; difference = 17%; 95% CI, 7.8%-25.1%; χ21 = 12.2; P < .001).The chatbot performed best on questions in the retina category (77% correct) and poorest in the neuro-ophthalmology category (58% correct). The chatbot demonstrated intermediate performance on questions from the ocular oncology (72% correct), pediatric ophthalmology (68% correct), uveitis (67% correct), and glaucoma (61% correct) categories. Conclusions and Relevance: In this study, the recent version of the chatbot accurately responded to approximately two-thirds of multiple-choice questions pertaining to ophthalmic cases based on imaging interpretation. The multimodal chatbot performed better on questions that did not rely on the interpretation of imaging modalities. As the use of multimodal chatbots becomes increasingly widespread, it is imperative to stress their appropriate integration within medical contexts.

Prophylaxis against intraocular pressure spikes following uncomplicated phacoemulsification: a systematic-review and meta-analysis.

BACKGROUND: To investigate the effect of perioperative intraocular pressure (IOP) lowering medications on controlling postoperative IOP following uncomplicated phacoemulsification. METHODS: Ovid MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched up until November 2022. Randomised controlled trials (RCTs) that assessed IOP change via applanation tonometry in medicated and control arms following uncomplicated cataract surgery in healthy eyes were included. The primary outcome was the weighted mean difference (WMD) of IOP at 2-8 h, 12-24 h, and 1-7 days postoperatively within each medication class or common fixed-combination formulations. Risk of bias was assessed using the revised risk of bias in randomised trials (RoB-2). Level of evidence was rated using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) RESULTS: From 702 screened articles, 30 RCTs involving 2986 eyes were included. There was a statistically significant reduction in IOP favouring treatment arms at 2-8 h (WMD = -3.87 mmHg; 95% CI [-4.75, -3.00]; p < 0.001) and 12-24 h (WMD = -2.69 mmHg; 95% CI [-3.36, -2.02]; p < 0.001), with the effect wearing off beyond 1 day (p = 0.18). Between medication classes, the largest effect at both 2-8 h and 12-24 h was observed with intracameral cholinergics or fixed-combination carbonic anhydrase inhibitor-beta-blocker (FCCB) formulations. Conversely, the smallest effect was observed with prostaglandin analogues, alpha-agonists, and topical carbonic anhydrase inhibitors (CAIs). CONCLUSION: Prophylaxis against acute IOP elevations following uncomplicated cataract surgery is effective. FCCB and intracameral cholinergics are the most effective ocular antihypertensive agents, while alpha-agonists, prostaglandin analogues, and topical CAIs were found to be the least effective. These findings may inform future surgical guidelines.

Association Between Sociodemographic Factors and Self-reported Glaucoma in the National Health Interview Survey: A Population-Based Analysis.

PURPOSE: To investigate the association between social determinants of health (SDH) in the domains of social and community context, education access, environmental context, economic stability, and healthcare access, with glaucoma prevalence. DESIGN: Cross-sectional study. METHODS: The study population consisted of adult participants who answered glaucoma-related questions on the 2017 National Health Interview Survey (NHIS), the most recent iteration that includes glaucoma-related questions. The main outcome measures included the relationships between SDH-related factors and self-reported glaucoma diagnosis as well as self-reported glaucomatous vision loss were examined using univariable and multivariable regression models. RESULTS: In total, 26,696 of 26,742 (99.83%) NHIS respondents were included, of whom 880 (3.30%) reported a glaucoma diagnosis and 275 (1.03%) reported glaucomatous vision loss. Participants were predominantly middle-aged (50.95 ± 18.60 years), female (54.75%), and non-Hispanic White (70.49%). In age-adjusted multivariable regression (n = 25,456), non-Hispanic Black race (odds ratio [OR] = 1.87, 99% CI = [1.37, 2.55], P < .001, compared to non-Hispanic White race) and poor health status (OR = 1.54, 99% CI = [1.00, 2.37], P = .01, compared to good health status) were significant predictors of glaucoma diagnosis. For glaucomatous vision loss, having an income below the poverty threshold (OR = 2.41, 99% CI = [1.12, 5.20], P = .003, compared to income ≥5 times the poverty threshold) was the only significant predictor in univariable analyses. No SDH-related factors were significantly associated with glaucomatous vision loss in multivariable analysis (n = 848). Multicollinearity was minimal (variation inflation factor<1.6 for all independent variables). CONCLUSIONS: Non-Hispanic Black race and poor health status were associated with self-reported glaucoma diagnosis. Physicians and policymakers may consider SDH when assessing clinical risk and designing public health interventions.

Relationship Between Disease and Treatment Factors in Diabetes With Vision Difficulty: A Cross-Sectional, Population-Based Analysis.

BACKGROUND AND OBJECTIVE: Relationships between disease and treatment factors of diabetes and vision difficulty remain largely unknown. This study investigated the relationship between disease and treatment factors in diabetes and participants' self-reported vision difficulty. PATIENTS AND METHODS: This was a cross-sectional, population-based analysis. Data from the National Health Interview Survey was used and analyzed through univariable and multivariable logistic regression. RESULTS: From the 29,464 included participants, logistic regression showed increased odds of self-reported vision difficulty among participants with diabetes (odds ratio [OR] = 2.14, P < 0.001), prediabetes (OR = 1.95, P < 0.001), or gestational diabetes (OR = 1.54, P < 0.001) compared to participants without diabetes. Those who reported having diabetes for more than a year had higher odds of vision difficulty (OR = 1.97, P = 0.02), as did those who were taking insulin (OR = 1.62, P < 0.001), those who had taken less insulin to save money within the past year (OR = 1.87, P = 0.01), and those who reported experiencing diabetes-related stress (OR = 2.14, P < 0.001). CONCLUSIONS: Duration of diabetes, diabetes-related stress, and taking less insulin than recommended to save money were associated with vision difficulty. [Ophthalmic Surg Lasers Imaging Retina 2024;55:142-153.].

PARS PLANA VITRECTOMY WITH OR WITHOUT INTERNAL LIMITING MEMBRANE PEEL FOR MACULAR HOLE: A Systematic Review and Meta-Analysis.

PURPOSE: To compare the efficacy and safety of pars plana vitrectomy with and without internal limiting membrane (ILM) peeling for macular hole (MH). METHODS: A systematic literature search on Ovid MEDLINE, Embase, Cochrane Library, and Google Scholar was performed from January 2000 to 2023. The primary outcome was the final best-corrected visual acuity (BCVA). Secondary outcomes included MH closure rates and the need for repeat surgery. The authors performed a random-effects meta-analysis on Review Manager 5.4. RESULTS: Fourteen studies on 880 eyes were included. Pars plana vitrectomy with and without ILM peel achieved a similar final BCVA ( P = 0.66). However, pars plana vitrectomy without ILM peeling achieved a significantly better final BCVA in eyes with closed MHs (WMD = 0.05 logMAR, 95% CI, 0.01-0.10, P = 0.02). Pars plana vitrectomy with ILM peeling achieved a significantly higher primary MH closure rate (RR = 1.21, 95% CI, 1.04-1.42, P = 0.02) and lower incidence of MH reoperation (RR = 0.19, 95% CI, 0.11-0.33, P < 0.001). The final MH closure rate ( P = 0.12) and incidence of MH recurrence ( P = 0.25) were similar between groups. CONCLUSION: Pars plana vitrectomy with and without ILM peel achieved a similar final BCVA. However, pars plana vitrectomy without ILM peeling achieved a better final BCVA in eyes with closed MHs. ILM peeling achieved a greater primary MH closure rate and reduced need for reoperation.