OCT analysis of preoperative foveal microstructure in recent-onset macula-off rhegmatogenous retinal detachment: visual acuity prognostic factors.

BACKGROUND: To evaluate, in patients undergoing macula-off rhegmatogenous retinal detachment surgery (RRD), the correlation between preoperative optical coherence tomography (OCT) morphological features and postoperative visual acuity. METHODS: Retrospective interventional non-randomised clinical trial on 89 eyes of 89 patients undergoing pars plana vitrectomy for macula-off primary RRD at Policlinico Universitario Agostino Gemelli from 2020 to 2023. Preoperative 6×6 mm OCT B scans with Nidek Mirante (Nidek, Gamagori, Japan) were performed, collecting the following features: foveal involvement (fovea-on vs fovea-off), subretinal hyper-reflective points (HRPs), outer retinal corrugations (ORCs) and intraretinal cystic spaces (ICS) in the outer nuclear layer. The patients were followed in a 6-month follow-up to evaluate best-corrected visual acuity (BCVA) outcomes. RESULTS: Preoperative mean BCVA was 0.15±0.22 and improved to 0.29±0.3 decimals at 6 months (p<0.001). The presence of subretinal HRPs showed a significant negative impact on BCVA improvement in the univariate regression analysis (r=-0.264, p=0.024), as well as the presence of foveal detachment (r=-0.355, p=0.012). The other OCT features did not show a significant correlation with BCVA improvement: ORCs (r=0.072, p=0.257) and ICS (r=-0.020, p=0.734). In the multivariate regression analysis, the negative impact of foveal detachment was confirmed (r=-0.199, p=0.05) while the statistical significance of subretinal HRPs was lost (r=-0.135, p=0.105). CONCLUSIONS: The negative impact of foveal involvement in a macula-off RRD was confirmed. Moreover, the presence of subretinal HRPs, as a possible indirect marker of inflammatory response extent, may act as a negative predictor for postoperative visual recover. TRIAL REGISTRATION NUMBER: NCT05747144.

Femtosecond laser-assisted astigmatic keratotomy versus toric IOL implantation for correcting astigmatism in cataract patients: a systematic review and meta-analysis with trial sequential analysis.

AIMS: To compare the refractive and visual outcomes of femtosecond laser-assisted astigmatic keratotomy (FSAK) and toric intraocular lens (IOL) implantation for correcting astigmatism in cataract patients. METHODS: Studies were retrieved from the Ovid-Medline, EMBASE, Cochrane Central Register of Controlled Trials and Scopus which compared FSAK and toric IOL for astigmatism correction in cataract patients. Outcome measures included postoperative refractive cylinder, correction index, uncorrected distance visual acuity (UDVA), the proportion of patients achieving a residual refractive cylinder of 1.00 dioptre or less, target-induced astigmatism (TIA) and surgically induced astigmatism (SIA). The trial sequential analysis (TSA) was used to collect firm evidence supporting our conclusion. RESULTS: 9 studies encompassing 590 participants were analysed. The meta-analysis revealed that toric IOLs could result in less postoperative refractive cylinder and provide better UDVA compared with FSAK. The TSA disclosed strong evidence of lower postoperative refractive cylinder in the toric IOL group compared with that of the FSAK group. FSAK showed a smaller correction index and lower mean TIA and SIA compared with toric IOLs. CONCLUSIONS: For cataract patients, both FSAK and toric IOLs are effective methods for correcting astigmatism. However, toric IOLs offer less postoperative astigmatism and result in better postoperative UDVA compared with FSAK. In vector analysis of astigmatism, toric IOLs can also produce higher TIA and SIA. Additionally, neither method is associated with severe untreatable complications. Therefore, the conclusion is that toric IOLs are the preferred choice for astigmatism correction in cataract patients and FSAK serves as a viable alternative when toric IOLs are contraindicated.

Exploring AI-chatbots' capability to suggest surgical planning in ophthalmology: ChatGPT versus Google Gemini analysis of retinal detachment cases.

BACKGROUND: We aimed to define the capability of three different publicly available large language models, Chat Generative Pretrained Transformer (ChatGPT-3.5), ChatGPT-4 and Google Gemini in analysing retinal detachment cases and suggesting the best possible surgical planning. METHODS: Analysis of 54 retinal detachments records entered into ChatGPT and Gemini's interfaces. After asking 'Specify what kind of surgical planning you would suggest and the eventual intraocular tamponade.' and collecting the given answers, we assessed the level of agreement with the common opinion of three expert vitreoretinal surgeons. Moreover, ChatGPT and Gemini answers were graded 1-5 (from poor to excellent quality), according to the Global Quality Score (GQS). RESULTS: After excluding 4 controversial cases, 50 cases were included. Overall, ChatGPT-3.5, ChatGPT-4 and Google Gemini surgical choices agreed with those of vitreoretinal surgeons in 40/50 (80%), 42/50 (84%) and 35/50 (70%) of cases. Google Gemini was not able to respond in five cases. Contingency analysis showed significant differences between ChatGPT-4 and Gemini (p=0.03). ChatGPT's GQS were 3.9±0.8 and 4.2±0.7 for versions 3.5 and 4, while Gemini scored 3.5±1.1. There was no statistical difference between the two ChatGPTs (p=0.22), while both outperformed Gemini scores (p=0.03 and p=0.002, respectively). The main source of error was endotamponade choice (14% for ChatGPT-3.5 and 4, and 12% for Google Gemini). Only ChatGPT-4 was able to suggest a combined phacovitrectomy approach. CONCLUSION: In conclusion, Google Gemini and ChatGPT evaluated vitreoretinal patients' records in a coherent manner, showing a good level of agreement with expert surgeons. According to the GQS, ChatGPT's recommendations were much more accurate and precise.

Evaluation and model to achieve sex parity in cataract surgical coverage in Theni district, India.

BACKGROUND/AIMS: To propose an approach to determine the target ratio of cataract surgical rates (CSRs) of female to male subpopulations to increase sex parity in cataract surgical coverage (CSC), based on the sex gap in cataract burden and incidence, and demonstrate its application to Theni district, India. METHODS: A population-based longitudinal study between January 2016 and April 2018. We recruited 24 327 participants using random cluster sampling. We conducted detailed eye examinations of 7087 participants aged ≥40 years (4098 females, 2989 males). We fit exponential models to the age-specific and sex-specific cataract burden and estimated annual incidence rates. We developed a spreadsheet-based planning tool to compute the target CSR ratio of female to male subpopulations. RESULTS: Among those aged ≥40 years, cataract burden was 21.4% for females and 17.5% for males (p<0.05). CSC was 73.9% for females versus 78.6% for males (p<0.05), with an effective CSC of 52.6% for females versus 57.6% for males (p<0.05). Treating only incident cataracts each year requires a target CSR ratio of female to male subpopulations of 1.30, while addressing in addition 10% of the coverage backlog for females and 5% for males requires a target CSR ratio of 1.48. CONCLUSIONS: The female population in Theni district, as in many low-income and middle-income countries, bears a higher cataract burden and lower CSC. To enhance sex parity in coverage, both the higher number of annual incident cataracts and the larger backlog in females will need to be addressed.

[Trabeculotomy (ab externo) as primary intervention for open-angle glaucoma : 5-year results]. / Trabekulotomie (ab externo) als Ersteingriff bei Offenwinkelglaukomen : 5-Jahres-Ergebnisse.

BACKGROUND: The published results of trabeculotomy ab externo (TOT), as an outflow channel surgery in adults with open-angle glaucoma, are underrepresented in comparison with other pressure-lowering glaucoma procedures. OBJECTIVE: To determine the long-term pressure lowering effect and complications of TOT as a stand-alone procedure or in combination with phacoemulsification with intraocular lens implantation (PIT) as a primary pressure-lowering procedure in adult patients with forms of chronic open-angle glaucoma. METHOD: This was a retrospective analysis of 121 eyes of 106 patients wherby 90 eyes underwent TOT and 31 eyes underwent PIT. The follow-up period was 5 years. Follow-up was performed in the same center under standardized conditions. Preoperative as well as postoperative best-corrected distance visual acuity, intraocular pressure, pressure-lowering medication, and complications were recorded. For success criterion 1, the intraocular pressure was not allowed to exceed 17 mm Hg at any control. For success criterion 2, the intraocular pressure was allowed to be above 17 mm Hg at 1 control throughout the follow-up period. RESULTS: Preoperative intraocular pressure in the TOT group was 25.92 mm Hg (SD 6.58) and 26.32 mm Hg (SD 6.06) in the PIT group. The annual cumulative success rates with pressure-lowering medications for success criterion 1 were 92.8%, 82.5%, 70.5%, 52.7% and 26.1%. For success criterion 2 these were 97.9%; 94.9%, 93.2%, 91.3%, and 89%. We found no relevant difference in pressure reduction between TOT and PIT. Without pressure-lowering medications, success rates were significantly lower for both success criteria. No serious complications occurred. The most common postoperative complication was spontaneously resorbable hyphema. CONCLUSION: Performing TOT or PIT as a primary glaucoma procedure for chronic open-angle glaucoma in adults is reasonable, has a significant pressure-lowering effect and very low complication rate.

Avaliação do colírio de brimonidina 0, 2% em comparação à nafazolina 0,025% + feniramina 0,3% nas cirurgias de estrabismo / Evaluation of 0.2% brimonidine eye drops compared to 0.025% naphazoline + 0.3% pheniramine in strabismus surgery

RESUMO Objetivo: Avaliar o efeito do colírio de brimonidina 0,2% na redução da hiperemia e do sangramento ocular durante as cirurgias de estrabismo, em comparação com o colírio de nafazolina 0,025% + feniramina 0,3%. Métodos: Foram avaliados 14 pacientes com estrabismo e indicação de correção cirúrgica bilateral. Foi instilado antes do procedimento, de forma aleatória, um colírio em cada olho dos pacientes avaliados. A análise subjetiva da hiperemia conjuntival e do sangramento perioperatório foi realizada de forma duplo-cega, por dois cirurgiões. A avaliação objetiva do nível de hiperemia conjuntival foi realizada por análise das imagens obtidas por meio do software ImageJ®. Resultados: A análise de modelos multivariados de efeito misto indicou diferenças estatisticamente significantes entre os grupos em relação à hiperemia (avaliador 2) e ao sangramento intraoperatório (avaliadores 1 e 2), com maiores escores nos casos tratados com colírio de nafazolina + feniramina. Entretanto, não houve diferença estatística na análise objetiva realizada por meio da saturação de cores obtidas pelo programa ImageJ®. Conclusão: O colírio de brimonidina pode ser superior ao colírio de nafazolina + feniramina na redução do sangramento, levando-se em conta apenas a análise subjetiva.

ABSTRACT Objective: To evaluate the effect of 0.2% brimonidine eye drops in reducing hyperemia and ocular bleeding during strabismus surgeries, in comparison with 0.025% naphazoline + 0.3% pheniramine eye drops. Methods: Fourteen patients with strabismus and indication for bilateral surgical correction were evaluated. Before the procedure, the eye drops were instilled randomly in each eye of the evaluated patients. The subjective analysis of conjunctival hyperemia and perioperative bleeding was performed in a double-blind manner, by 02 surgeons. The objective assessment of the level of conjunctival hyperemia was performed by analyzing the images obtained using the ImageJ® software. Results: The analysis of multivariate mixed effect models indicated statistically significant differences between the groups in relation to hyperemia (rater 2) and intraoperative bleeding (raters 1 and 2) with higher scores in cases treated with naphazoline + pheniramine eye drops. However, there were no statistically significant differences in the objective analysis of color saturation obtained by the ImageJ® program. Conclusion: Brimonidine eye drops may be superior to naphazoline + pheniramine eye drops in reducing bleeding, taking into account the subjective analysis only.

Complicated trabeculectomy converted into ab externo cyclodialysis

ABSTRACT The creation of a scleral flap during trabeculectomy can be complicated by a buttonhole, partial amputation at the limbus, and extensive thinning. In some cases, the procedure must be aborted to prevent more serious postoperative complications. This report describes a technique of converting complicated trabeculectomy into ab externo cyclodialysis. A 41-year-old patient with congenital glaucoma presented with a perforated scleral wall with the choroidal tissue exposed during the dissection of the partial-thickness scleral flap. By using a Barraquer cyclodialysis spatula through the scleral perforation, the choroid was separated from the sclera up to the scleral spur over 30° into the anterior chamber. The sclera and conjunctiva/Tenon were sutured with 10-0 nylon single sutures. Two months later, the intraocular pressure was reduced to 16 mmHg with no hypotensive topical medications. This case illustrates an alternative approach to managing a flap-related perioperative complication in trabeculectomy, which yielded good early results.

Surveillance system for Healthcare-associated endophthalmitis at state level in a middle-income country: preliminary results / Sistema de vigilância epidemiológica para endoftalmites em nível estadual em um país de renda média: resultados preliminares

ABSTRACT Purpose: To describe the implementation pro cess and the preliminary results of a surveillance system for healthcare-associated endophthalmitis. Methods: This is a case study of the implementation of a surveillance system for healthcare-associated endophthalmitis. The system for healthcare-associated endophthalmitis is a structured system that enables surveillance of cases of healthcare-associated endophthalmitis after intraocular procedures, developed and coordinated by the Division of Hospital Infection at the State Health Department, São Paulo, Brazil. The implementation process included a pilot phase, followed by a scaling-up phase. Data were reported monthly to the Division of Hospital Infection by participating healthcare facilities that performed intraocular procedures in the state of São Paulo, Brazil, from September 2017 to December 2019. Results: Among the 1,483 eligible healthcare facilities, 175 engaged in the study (participation rate of 11.8%), reporting 222,728 intraocular procedures performed, of which 164,207 were cataract surgery and 58,521 were intravitreal injections. The overall incidence rate of endophthalmitis was reported to be 0.05% (n=105; 80 cases after cataract surgery and 25 cases after intravitreal injections). The incidence rates for healthcare facilities ranged from 0.02% to 4.55%. Most cases were caused by gram-positive bacteria, mainly Staphylococcus spp. In 36 (46.2%) of the cases, there was no bacterial growth; no sample was collected in 28 (26.7%) cases. This system for healthcare-associated endophthalmitis enabled the identification of an outbreak of four cases of endophthalmitis after intravitreal injections. Conclusion: The system for healthcare-associated endophthalmitis proved to be operationally viable and efficient for monitoring cases of endophthalmitis at the state level.

RESUMO Objetivo: Descrever o processo de implementação e os resultados preliminares de um sistema de vigilância epidemiológica para endoftalmites associada à assistência à saúde. Métodos: Trata-se de um estudo de caso de implementação de um sistema de vigilância epidemiológica para endoftalmites. O sistema de vigilância epidemiológica para endoftalmites é um sistema estruturado que possibilita a vigilância de casos de endoftalmite associados à assistência à saúde após procedimentos oftalmológicos invasivos, desenvolvido e coordenado pela Divisão de Infecção Hospitalar da Secretaria de Estado da Saúde, São Paulo, Brasil. O processo de implementação incluiu uma fase piloto, seguida pela fase de expansão. Os dados foram enviados mensalmente à Divisão de Infecção Hospitalar pelos estabelecimentos de saúde participantes que realizaram procedimentos oftalmológicos no estado de São Paulo, Brasil no período de setembro de 2017 a dezembro de 2019. Resultados: Entre os 1.483 estabelecimentos de saúde elegíveis, 175 participaram do estudo (taxa de adesão de 11,8%), relatando 222.728 procedimentos oftalmológicos realizados, sendo 164.207 cirurgias de catarata e 58.521 injeções intravítreas. A taxa de incidência global de endoftalmite relatada foi de 0,05% (n=105; 80 casos após cirurgia de catarata e 25 casos após injeção intravítrea). As taxas de incidência entre os estabelecimentos de saúde variaram de 0,02% a 4,55%. A maioria dos casos foi causada por bactérias gram-positivas, principalmente Staphylococcus spp. Em 36 (46,2%) casos não houve crescimento bacteriano; nenhuma amostra foi coletada em 28 (26,7%) casos. O sistema de vigilância epidemiológica para endoftalmites possibilitou a identificação de um surto de quatro casos de endoftalmite após injeção intravítrea. Conclusão: O sistema de vigilância epidemiológica para endoftalmites mostrou-se operacionalmente viável e eficiente para o monitoramento de casos de endoftalmite em nível estadual.

Post-Bader procedure: a long-term follow-up case study / Procedimento pós-Bader: estudo de caso com acompanhamento de longo prazo

ABSTRACT Keratoconus is a progressive disorder that manifests as a cone-like steepening of the central or paracentral inferior cornea and irregular stromal thinning. There is a gradual decrease in visual acuity due to corneal asymmetry, irregular astigmatism, and increased optical aberrations, consequently impacting the quality of life. Several procedures have been developed in an attempt to slow or reverse the progression. The Bader procedure, which includes a pattern of incisions around the circumference of the cornea and at the base of the protruding cone, is one such surgery. These incisions penetrate 70-90% of the cornea's depth. Its goal is to flatten the topography and reduce corneal asymmetry and irregular astigmatism. Though prior research found these to be highly promising, we report a patient who was given contact lenses to restore and maintain his vision while his corneal ectasia and thinning progressed over the following decade.

RESUMO O ceratocone é uma doença progressiva que se manifesta como uma elevação semelhante a um cone da cór­nea central ou paracentral inferior e é associada a uma re­dução irregular da espessura do estroma. Há uma diminuição gradual da acuidade visual devido à assimetria da córnea, ao astigmatismo irregular e a um aumento das aberrações ópticas, o que prejudica a qualidade de vida. Foram desenvolvidos vários procedimentos para tentar interromper ou mesmo reverter a evolução da doença. Um deles é o chamado procedimento de Bader, que inclui um padrão de incisões em volta da circunferência da córnea e na base do cone protuberante. Essas incisões penetram até 70%-90% da profundidade da córnea e têm o objetivo de achatar a topografia e diminuir a assimetria da córnea e o astigmatismo irregular. Embora essa técnica seja muito promissora, segundo um estudo anterior, aqui se apresenta o caso de um paciente no qual esses objetivos não foram atingidos. Esse paciente recebeu lentes de contato para restaurar e manter sua visão, enquanto sua ectasia corneana e a redução da espessura progrediram ao longo da década seguinte.

Paracentral acute middle maculopathy in the immediate postoperative of cataract surgery / Maculopatia média aguda paracentral no pós-operatório imediato de cirurgia de catarata

ABSTRACT This case report identified paracentral acute middle maculopathy as the cause of severe and irreversible vision loss after cataract surgery. Cataract surgeons should be aware of known risk factors for the development of paracentral acute middle maculopathy. In those patients, extra care regarding anesthesia, intraocular pressure, and some other aspects of cataract surgery must be taken. Paracentral acute middle maculopathy is currently understood as a clinical sign evident on spectral-domain optical coherence tomography, and it is probably evidence of deep ischemic insult to the retina. It should be a differential diagnosis in cases of marked low vision acuity associated with no fundus abnormalities in the immediate postoperative period, as demonstrated in the presented case.

RESUMO O presente relato de caso identificou a maculopatia média aguda paracentral como a causa de baixa de acuidade visual severa e irreversível após cirurgia de catarata. Existem fatores de risco bem estabelecidos para o desenvolvimento da maculopatia média aguda paracentral que devem ser conhecidos pelos cirurgiões de catarata. Nesse contexto cirúrgico, precauções extras no tocante a procedimentos anestésicos, pressão intraocular e alguns outros aspectos da cirurgia devem ser consideradas. A maculopatia média aguda paracentral é descrita como um sinal clínico observado no exame de tomografia de coerência óptica por domínio espectral e se trata, provavelmente, da evidência de um evento isquêmico no tecido vascular retiniano. Esse diagnóstico deve ser cogitado nos casos de perda de acuidade visual súbita no pós-operatório imediato associada com exame fundoscópico normal, como evidenciado no caso apresentado.

Long-term outcomes of deep anterior lamellar versus penetrating keratoplasty for keratoconus.

AIMS: To compare the long-term outcomes of deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in keratoconus. METHODS: Retrospective comparative case series (228 DALKs and 274 PKs). A biphasic linear model was used to describe the postoperative outcome of the endothelial cell density (ECD). Visual acuity, specular microscopy, corneal topography and optical coherence tomography findings were recorded. RESULTS: Graft survival of the 502 keratoconus eyes was 96.7 at 10 years and 95.6% at 20 years. Visual acuity improved from 20/378±5.1 lines preoperatively to 20/32±2.1 lines at 30 months. The corneal ECD decreased from 2494±382 cells/mm2 to 1521±659 cells/mm2 at 10 years. The mean simulated keratometry increased from 44.88±2.54 D at 1 year to 46.60±3.0 D at 3 years. The mean follow-up was 103.4 months for DALKs and 106.1 months for PKs. The cumulated incidence of postoperative ocular hypertension requiring treatment was significantly higher in PKs than in DALKs. The early- and late-phase rates of ECD loss were significantly lower in DALKs than in PKs. These figures in DALKs were 50% of those observed in PKs. The simulated mean keratometry was significantly higher in DALKs than in PKs in the mid but not in the long term. No significant differences in visual acuity were observed between both groups. Manual dissection-DALK featured slower visual recovery than PK and big bubble-DALK, whereas big bubble-DALK and PK featured similar visual recovery. CONCLUSIONS: DALK featuring higher endothelial survival and lower risk of postoperative ocular hypertension may be superior to PK when indicated for keratoconus.

Trabecular microbypass as replacement therapy in pharmacologically controlled open-angle glaucoma patients / Implante de by-pass trabecular como alternativa aos colírios em portadores de glaucoma de ângulo aberto controlados com tratamento clínico

ABSTRACT Purpose: To assess the outcomes of the trabecular bypass as replacement therapy for medications in pharmacologically controlled vs. pharmacologically uncontrolled open-angle glaucoma patients. Methods: This was a retrospective study of eyes treated with first- (iStent) or second-generation (iStent inject) trabecular bypass. Group 1 consisted of eyes with pharmacologically controlled intraocular pressure <18 mmHg and Group 2 consisted of eyes with pharmacologically controlled intraocular pressure ≥18 mmHg. The main outcomes measured were qualified (with or without medications) and unqualified or complete (without medications) success rates at different target intraocular pressures, mean reduction (%) in medication use, and proportion of medication-free eyes. Results: The mean age was 70.4 years in Group 1 (n=105) and 68.1 years in Group 2 (n=65). Qualified success rates for intraocular pressure <18 mmHg, intraocular pressure <15 mmHg, and intraocular pressure <12 mmHg were similar between the groups (Group 1: 96.2%, 88.6%, and 32.4%, respectively; Group 2: 93.8%, 78.5%, and 21.5%, respectively; all p>0.05). Complete success rates were significantly higher in Group 1 than in Group 2: for intraocular pressure <18 mmHg (76.2% vs. 47.7%), intraocular pressure <15 mmHg (73.3% vs. 40.0%), and intraocular pressure <12 mmHg (14.3% vs. 4.6%). The mean reduction in medication use was higher in Group 1 than in Group 2. At the end of follow-up, 79.0% of eyes in Group 1 and 47.7% of eyes in Group 2 became medication-free. Conclusions: Both groups showed high qualified success rates, but eyes with baseline pharmacologically controlled intraocular pressure <18 mmHg showed higher complete success rates and greater chances of achieving no need for medications.

RESUMO Objetivo: Avaliar os resultados dos implantes de by-pass trabecular como terapia de substituição aos colírios em pacientes com glaucoma de ângulo aberto controlados com medicação vs. não controlados com medicação. Métodos: Este foi um estudo retrospectivo de olhos submetidos a cirurgia de implante de by-pass trabecular de primeira (iStent) ou segunda geração (iStent inject). O Grupo 1 consistiu em olhos com pressão intraocular medicada <18 mmHg e o Grupo 2 consistiu em olhos com pressão intraocular medicada ≥18 mmHg. Os principais desfechos foram as taxas de sucesso relativo (com ou sem medicamentos) e completo (sem medicamentos) em diferentes pressões intraoculares-alvo, redução média (%) no uso de medicamentos e proporção de olhos sem medicamentos. Resultados: A média de idade foi de 70,4 anos no Grupo 1 (n=105) e 68,1 anos no Grupo 2 (n=65). As taxas de sucesso relativo para pressão intraocular <18 mmHg, pressão intraocular <15 mmHg e pressão intraocular <12 mmHg foram semelhantes entre os grupos (Grupo 1: 96,2%, 88,6% e 32,4%, respectivamente; Grupo 2: 93,8%, 78,5% e 21,5%, respectivamente; todos p>0,05). As taxas de sucesso completo foram significativa mente maiores no Grupo 1 do que no Grupo 2: pressão intraocular <18 mmHg (76,2% vs. 47,7%); pressão intraocular <15 mmHg (73,3% vs. 40%); pressão intraocular <12 mmHg (14,3% vs. 4,6%). A redução média no uso de medicamentos foi maior no Grupo 1 do que no Grupo 2. Ao final do acompanhamento, 79,0% dos olhos do Grupo 1 e 47,7% dos olhos do Grupo 2 estavam livres medicamentos. Conclusões: Ambos os grupos mostraram altas taxas de sucesso relativo, mas olhos com pressão intraocular medicada pré-operatória <18 mmHg apresentaram taxas de sucesso completo mais elevadas, bem como maiores chances de se tornarem livres de medicamentos para glaucoma.

Simultaneous posterior eyelid ptosis repair and strabismus surgery: a single-stage approach / Cirurgia reparadora simultânea de blefaroptose posterior e de estrabismo: abordagem de estágio único

ABSTRACT Purpose: Blepharoptosis with coexisting strabismus can be observed in adults, and both these conditions affect cosmetic appearance and have psychosocial effects. Both also commonly require surgery, which is typically performed using a sequential approach. This study aimed to evaluate the efficacy of simultaneous Müller's muscle-conjunctival resection with or without tarsectomy and strabismus surgery in adult patients with ptosis and coexisting strabismus. Methods: Patients with ptosis and coexisting strabismus who underwent simultaneous Müller's muscle-conjunctival resection with or without tarsectomy and horizontal strabismus surgery were retrospectively evaluated. Analysis included measurement of the angle of deviation in prism diopters, margin reflex distance, eyelid height asymmetry, and complications following surgery. Success of Müller's muscle-conjunctival resection with or without tarsectomy was defined as a margin reflex distance of ≥3.5 and ≤5 mm with a difference between the two upper eyelids of <1 mm. Strabismus success was defined as alignment with ±10 prism diopters of orthotropia. Results: The patients comprised three women and five men with a mean age of 37.12 years (range, 22-62 years). The strabismus stage of the surgery was performed first in all patients. Upper eyelid symmetry outcomes were assessed as perfect (<0.5 mm) in four patients and good (≥0.5 mm, <1 mm) in four patients. Success of Müller's muscle-conjunctival resection with or without tarsectomy was achieved in six of eight patients (75%), and strabismus success was achieved in all patients. No revision eyelid or strabismus surgery was required following simultaneous surgery in any of the patients. Conclusion: Müller's muscle-conjunctival resection with or without tarsectomy combined with strabismus surgery may be an alternative approach for use in patients with ptosis and coexisting strabismus.

RESUMO Objetivo: Blefaroptose e estrabismo podem ser coexistentes em adultos e ambos afetam a aparência estética e o domínio psicossocial. Ambos também geralmente requerem cirurgia, realizada tradicionalmente em uma abordagem sequencial. O objetivo do presente estudo foi avaliar a eficácia da execução simultânea da ressecção musculoconjuntival de Müller, com ou sem cirurgia de tarsectomia, e da cirurgia de estrabismo em pacientes adultos com ptose e estrabismo coexistentes. Métodos: Foram retrospectivamente avaliados pacientes com ptose e estrabismo coexistentes submetidos simultaneamente à ressecção musculoconjuntival de Müller, com ou sem tarsectomia, e à cirurgia de estrabismo horizontal. A análise incluiu a mensuração do ângulo de desvio das dioptrias de prisma, a distância do reflexo à margem, a assimetria da altura palpebral e quaisquer complicações após a cirurgia. A ressecção musculoconjuntival de Müller, com ou sem sucesso na tarsectomia, foi considerada bem-sucedida com uma distância reflexo-margem medindo entre 3,5 e 5 mm, e uma diferença entre as duas pálpebras superiores menor que 1 mm. O sucesso da cirurgia de estrabismo foi definido como um alinhamento com ± 10 dioptrias prismáticas de ortotropia. Resultados: Os pacientes foram 3 mulheres e 5 homens, com média de idade de 37,12 anos (faixa de 22 a 62 anos). A parte de estrabismo da cirurgia foi realizada primeiro em todos os pacientes. Os resultados da simetria palpebral superior foram avaliados como perfeitos (<0,5 mm) em 4 pacientes, bons (≥0,5 mm, <1 mm) em 4 pacientes e regulares (≥1 mm) em nenhum. A ressecção musculoconjuntival de Müller, com ou sem sucesso na tarsectomia, teve sucesso em 6 dos 8 pacientes (75%) e a intervenção para o estrabismo foi bem-sucedida em todos os pacientes. Não foi necessária cirurgia de revisão da pálpebra ou do estrabismo após a cirurgia simultânea em nenhum paciente. Conclusão: A ressecção musculoconjuntival de Müller, com ou sem tarsectomia, pode ser combinada com a cirurgia de estrabismo em uma abordagem alternativa para pacientes com ptose e estrabismo coexistentes.

Role of artificial intelligence in determining factors impacting patients' refractive surgery decisions.

Purpose: To create a predictive model using artificial intelligence (AI) and assess if available data from patients' registration records can help in predicting definitive endpoints such as the probability of patients signing up for refractive surgery. Methods: This was a retrospective analysis. Electronic health records data of 423 patients presenting to the refractive surgery department were incorporated into models using multivariable logistic regression, decision trees classifier, and random forest (RF). Mean area under the receiver operating characteristic curve (ROC-AUC), sensitivity (Se), specificity (Sp), classification accuracy, precision, recall, and F1-score were calculated for each model to evaluate performance. Results: The RF classifier provided the best output among the various models, and the top variables identified in this study by the RF classifier excluding income were insurance, time spent in the clinic, age, occupation, residence, source of referral, and so on. About 93% of the cases that did undergo refractive surgery were correctly predicted as having undergone refractive surgery. The AI model achieved an ROC-AUC of 0.945 with an Se of 88% and Sp of 92.5%. Conclusion: This study demonstrated the importance of stratification and identifying various factors using an AI model which could impact patients' decisions while selecting a refractive surgery. Eye centers can build specialized prediction profiles across disease categories and may allow for the identification of prospective obstacles in the patient's decision-making process, as well as strategies for dealing with them.

Surgical Management of Bilateral Limbal Stem Cell Deficiency.

At the age of 43 years-old, a man was left with bilateral limbal stem cell deficiency after an ocular alkaline burn with lime, which resulted in corneal opacification. After multiple unsuccessful surgical attempts to restore vision, including penetrating keratoplasties and Boston keratoprosthesis, visual acuity was counting fingers in the left eye. At 73 years of age, the patient underwent another surgery in his left eye. Cauterization of neovessels and removal of the vascular pannus were followed by partial excision of Tenon's capsule. Penetrating keratoplasty was followed by an intrastromal injection of anti-VEGF (vascular endothelial growth factor), and the ocular surface was covered with amniotic membrane. Postoperatively, the graft was clear with no signs of inflammation; vision improved to 20/50 and remained stable throughout the following two years. Herein we describe some adjunctive procedures that might have delayed failure and rejection of the corneal graft. This case demonstrates the difficulties in treating bilateral limbal stem cell deficiency in a tertiary eye care center with no capacity to perform stem cell therapy.

Ultrasound-guided versus conventional peribulbar anaesthesia in cataract surgery: A randomised controlled study.

BACKGROUND: Blind ophthalmic anaesthetic techniques may have serious complications. AIM: To assess the safety of ultrasound as a guide in ophthalmic blocks. METHODS: Fifty adult patients undergoing cataract surgery under peribulbar block anaesthesia were randomly assigned to ultrasound-guided and conventional block groups. In the ultrasound-guided block group, a large amount of the standard ultrasound gel was applied to the closed eyelids. The globes were scanned in both sagittal and transverse planes. The patients were asked to look straight ahead with closed eyes without clenching the eyelids. The depth and gain were adjusted before performing the block. The primary outcome was the rate of complications. Secondary outcomes included the volume of injected anaesthetics and surgeon and patients' satisfaction. RESULTS: The local anaesthetic volume used was not significantly different between the two groups (7.08 ± 1.66 and 6.72 ± 1.97ml). The block onset, time and quality were comparable in both groups. No complications were reported, and there were no significant differences regarding surgeons' or patients' satisfaction with either procedure. CONCLUSION: The ultrasound-guided local ophthalmic block is as safe as the conventional method. Although its use was not superior to the conventional procedure, direct visualisation with ultrasound may be important to avoid vulnerable structures such as staphylomas.

A Comparative Study of the Effect of Anesthesia Induction with the Use of Four Drug Combinations Including "Propofol," "Etomidate-Propofol," "Thiopental," and "Midazolam-Thiopental" on Hemodynamic Changes during the Insertion of Laryngeal Mask in Eye Surgery.

Background: This study aimed to compare the efficacies of four anesthetic induction drugs (thiopental, propofol, midazolam-thiopental, and etomidate-propofol) on cardiovascular response during laryngeal mask airway (LMA) placement in eye surgery. Materials and Methods: The present clinical trial study included 128 patients who were candidates for ophthalmic surgery in four groups. Patients in the first group were given a combination of midazolam (0.04 mg/kg) with thiopental (2.5 mg/kg) (Group T + M). We administered propofol alone (2.5 mg/kg) to patients in the second group (Group P). The third group received a combination of etomidate (0.1 mg/kg) with propofol (1 mg/kg) (ET + P group) and patients in the fourth group received thiopental drug (5 mg/kg) alone (Group T). Then, the stability of patients' hemodynamic parameters before anesthesia was evaluated and compared immediately after anesthesia, 1, 3, and 5 min after LMA placement. Results: There was no significant difference between the four groups in changes in oxygen saturation level (P > 0.05). Furthermore, the difference between decreased systolic blood pressure and diastolic blood pressure over time was not significant in 5 min in both Groups T + M and T (P > 0.05). In addition, the stability of these two groups was higher than the other two groups (P < 0.05) and the most unstable group was Group P. The changes pulse ratein the P group were significant (P < 0.05). Conclusion: According to the results of the current study, thiopental and Midazolam can be used as an effective induction compound to facilitate LMA insertion with higher hemodynamic stability compared to propofol alone, propofol and etomidate, and thiopental alone.

The impact of COVID-19 on ophthalmology resident surgical experience: a retrospective cross-sectional analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused significant disruption to in-office and surgical procedures in the field of ophthalmology. The magnitude of the impact of the pandemic on surgical training among ophthalmology residents is not known. This study aims to quantify changes in average case logs among United States (U.S.) ophthalmology residency graduates prior to and during the COVID-19 pandemic. METHODS: Retrospective, cross-sectional analysis of aggregate, national data on case logs of U.S. ophthalmology residency graduates from 2012 to 2020. The yearly percent change in the average number of procedures performed in the Accreditation Council for Graduate Medical Education (ACGME) ophthalmology resident case logs were analyzed using linear regression on log-transformed dependent variables. The average percent change from 2019 to 2020 was compared to the average yearly percent change from 2012 to 2019 for procedures performed as the primary surgeon, and primary surgeon and surgical assistant (S + A), as well as procedures for which there are ACGME minimum graduating numbers. RESULTS: Across all procedures and roles, average case logs in 2020 were lower than the averages in 2019. While average total cases logged as primary surgeon increased yearly by 3.2% (95% CI: 2.7, 3.8%, p < 0.001) from 2012 to 2019, total primary surgeon case logs decreased by 11.2% from 2019 to 2020. Cataract (-22.0%) and keratorefractive (-21.1%) surgery experienced the greatest percent decrease in average primary surgeon cases logged from 2019 to 2020. Average total cases logged as S + A experienced an average yearly increase by 1.2% (95% CI: 0.9,1.6%, p < 0.001) prior to 2020, but decreased by 9.6% from 2019 to 2020. For ACGME minimum requirements, similar changes were observed. Specifically, the average case logs in YAG, SLT, filtering (glaucoma), and intravitreal injections had been increasing significantly prior to 2020 (p < 0.05 for all) but decreased in 2020. CONCLUSIONS: These findings demonstrate the vulnerability of ophthalmology residency programs to a significant interruption in surgical volume. There is a critical need for development of competency-based, rather than volume-based, requirements to evaluate readiness for independent practice.

The Value of Routine Tests before Pediatric Eye Surgery: A 10-Year Experience at a Tertiary Care Hospital.

Background: Routine tests before ophthalmologic surgery in adult patients are no longer recommended. However, there are limited data on the utility of routine preoperative tests for children. Aims: We aimed to describe the effect of routine preoperative tests on systemic perioperative complications by hospital discharge or by day 30 following eye surgery. Settings and Design: This was a single-center, observational, and descriptive study. Subjects and Methods: We examined all patients ≤ 17 years old for whom ophthalmologists consulted with anesthesiologists before eye surgery under general anesthesia in an academic teaching tertiary care hospital from January 2010 to December 2019. Results: A total of 708 pediatric patients were analyzed. The mean patient age was 8.5 ± 4.6 years. The most frequently performed procedure was strabismus surgery in 433 patients (61.2%). Following anesthetic consultations, 15 patients (2.1%) underwent surgery postponed due to abnormalities at the physical examination. Routine tests identified that the two patients (0.3%) required additional evaluations due to elevated serum creatine kinase and electrocardiographic abnormalities. However, further examinations found that these abnormalities were unremarkable. The remaining 691 patients (97.6%) underwent surgery as scheduled. Substantial intraoperative blood loss was observed only in three patients with malignant tumors or trauma. The incidence of systemic complications was 0 (0%; 95% confidence interval, 0%-0.05%). Conclusions: These data indicated that the development of systemic perioperative complications following pediatric ophthalmic surgery is rare. Preoperative tests should be requested only if they are clinically indicated or before potentially bleeding procedures, such as malignancy or trauma surgery.