Eye

Background/Aims: To evaluate the impact of socioeconomic deprivation on clinical presentation and outcomes of bacterial keratitis (BK) in the United Kingdom. Methods: A retrospective multicentre cohort study of 320 patients with BK presenting to two UK tertiary ophthalmic centres. Demographic, clinical and microbiological data were extracted from electronic health records. Socioeconomic status was assigned using residential postcodes mapped to the 2019 English Index of Multiple Deprivation (IMD) and grouped into quintiles (Q1 most deprived; Q5 least deprived). Presenting severity and outcomes were compared across IMD quintiles. Results: The mean age was 54.0{+/-}20.9 years; 50.6% were male and 83.4% were White. Mean presenting CDVA was 1.10{+/-}1.01 logMAR and time to presentation was a median of 3 days (IQR 1-6). Most cases had a small infiltrate (<3 mm; 68.4%), small epithelial defect (<3 mm; 63.4%) and no hypopyon (72.5%). Hospitalisation was required in 50.0%, and 17.5% underwent surgery. Culture positivity was 36.3%. There were no significant differences in presenting CDVA, time to presentation, clinical severity, admission, microbiological profile, surgical intervention or final CDVA across IMD quintiles (all p>0.05). Final CDVA improved to 0.75{+/-}0.96 logMAR (p<0.001). On multivariable analysis, poorer final CDVA was associated with worse presenting CDVA, increasing age and Gram-positive organisms, but not IMD. Conclusion: Socioeconomic deprivation did not influence the clinical presentation or outcomes in BK. Clinical severity at presentation and microbiological profile were the principal determinants of outcome. In this acute, painful sight-threatening condition, deprivation-related disparities may be attenuated by prompt presentation and universal access to emergency ophthalmic care.

BackgroundTo report insights on proliferative-diabetic-retinopathy (PDR) risk modification with repeated anti-vascular endothelial-growth-factor (VEGF) injections for the treatment of diabetic-macular-oedema (DMO) in routine care, and present data-driven PDR screening recommendations for injection clinics. MethodsMulticentre study (27 UK-NHS centres) of patients with non-PDR with and without DMO. Primary outcome was PDR development. Repeated anti-VEGF injections were modelled as time-dependent covariates using Cox regression and weighted cumulative exposure (WCE) adjusting for baseline diabetic retinopathy (DR) grade, age, sex, ethnicity, type of diabetes, and deprivation. A propensity score matched cohort was used to estimate the treatment effect on PDR incidence rates (IR). ResultsWe included 5716 NPDR eyes (5716 patients, 2858 DMO eyes). The WCE method showed a better model fit. Anti-VEGF injections showed a protective effect on risk of PDR during the most recent 4-weeks from exposure which rapidly decreased. There was a 20% reduction in risk of PDR (p0.006) in treated eyes. Severe-NPDR had a 4.6-fold increase in PDR hazards when compared with mild-NPDR (p<0.001). The annual IR of untreated mild-NPDR cases was 2.3 [95%CI 1.57-3.23] per 100 person-years). In NPDR DMO cases treated with anti-VEGF, similar IR would occur with annual review for mild, 6-monthly for moderate, and 3-monthly for severe-NPDR. ConclusionThe WCE method is a better modelling strategy than traditional Cox models for repeated exposures in ophthalmology. Injections are protective against PDR predominantly within the most recent 4 weeks. Based on observed data, we suggest follow-up recommendations for PDR detection according to retinopathy grade at first injection. PrecisThis study describes the impact on PDR risk of anti-VEGF injections for DMO in routine care and data-driven reassessment recommendations of the peripheral retina for people in long term injection clinics. Key messages What is already known on this topic- Clinical trials have shown that intravitreal anti-vascular endothelial growth factor (VEGF) injections reduce the incidence rate of proliferative diabetic retinopathy (PDR). - Repeated intravitreal anti-VEGF injections are the mainstay of treatment for diabetic macular oedema (DMO), however, there is little evidence on how these exposures impact on the risk of PDR in clinical practice. What this study adds- The impact of anti-VEGF on PDR risk varies based on the timing of exposure and the effect is not permanent. - Despite repeated treatments with anti-VEGF injections, patients with DMO may still progress to PDR. How this study might affect research, practice, or policy- Our work underscores the significance of taking into account repeated treatments at varying time intervals in ophthalmology, highlighting the utility of the weighted cumulative exposure method. - Implementing adequate modelling strategies to address the complexities of exposures in clinical settings can improve predictions and patient outcomes. - We provide PDR screening recommendations for DMO patients undergoing anti-VEGF treatments in injection clinics. Implementation would improve the safety and efficiency of treatment pathways.

BackgroundPatients with retinal diseases and their relatives face many challenges that may negatively impact treatment adherence that is required to maintain visual acuity. Patient support programmes (PSPs) may contribute to improve the understanding of the disease/therapy and promote intrinsically motivated treatment adherence. MethodsIn September 2023, a PSP was established for patients with neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME) or macular oedema due to retinal vein occlusion (RVO) and their relatives. As part of the PSP, each participant is individually supported by a personal contact through regular support calls. To gain an increasingly better understanding of patient needs, reactively collected health- and therapy-related data is stored in an anonymised manner. ResultsSince the start of the PSP, a total of 207 participants have registered for the PSP, with the majority being patients with nAMD (77.8%). The main topic of interest among patients and relatives was the diagnosis of nAMD (25.4% and 26.4% of respective inbound calls). Key patient topics also included treatment-related aspects such as application intervals (16.8%), treatment adherence (11.2%) and nAMD therapy (12.2%). Relatives were particularly interested in legal and social issues and assistive devices (14.3% and 13.2%, respectively). ConclusionsThe results indicate that there is a need for an individual care, e.g. provided by a PSP, for patients with retinal diseases. PSPs should be considered a complementary support to the medical treatment or care provided by physicians.

ObjectiveTo perform a systematic review and meta-analysis of the clinical evidence of the treatment effect of surgical cyclodialysis in the management of intraocular (IOP) in patients with glaucoma. MethodsA comprehensive literature review was conducted of peer-reviewed interventional studies from the PubMed, Cochrane, Web of Science and EMBASE databases of surgical cyclodialysis treatment for the lowering of intraocular pressure in patients with glaucoma. Key outcome measures of treatment success were long-term IOP control, as well as IOP-lowering medication burden and the incidence of intraoperative and postoperative adverse events. The meta-analysis was registered with Prospero ID CRD42025632759 ResultsA total of 40 studies spanning a publication period of more than 100 years of surgical cyclodialysis treatment encompassing data from over 4,082 eyes were included in the analysis. Clinical evidence comprised observational, non-randomized studies, 75% of which involved an ab-externo approach and 25% comprised an ab-interno cyclodialysis intervention. Given the natural evolution of the clinical paradigm over the years, changes in surgical technique, instrumentation and addressable population, the overall analysis was constructed to account for the significant variability in outcomes reporting. Across the final evaluable dataset, the clinical performance of cyclodialysis surgery was characterized by overall qualified success rates of 72.3% on average (range 33%-97%) over a postoperative follow-up period ranging from 6 to 132 months. Depending on surgical technique and disease severity, reported success rates indicate slightly increased efficacy and lower rate of complications with ab-interno intervention. Durability of the cyclodialysis procedure varied significantly, with higher rates of failure in patients with advanced and refractory glaucoma. Specific complications such as persistent hyphema, hypotony and vision loss were reported infrequently. All outcomes, including IOP reduction, ocular safety, and durability, showed significant improvement with the newer interventional ab-interno surgical techniques. ConclusionCyclodialysis remains an enduring surgical intervention and one of the few available surgical options for uveoscleral outflow enhancement in glaucoma patients. The IOP lowering effect of the procedure can be significant, albeit variable, with better clinical performance in mild and moderate glaucoma and with advanced interventional ab-interno surgical approaches. SynopsisResults of a meta-analysis comprising more than 4,000 glaucoma cases of cyclodialysis surgery for the lowering of intraocular pressure demonstrate significant and sustained efficacy of one of the few surgical interventions for uveoscleral outflow enhancement.

AimTo interpret the likely clinical susceptibility of isolates from microbial keratitis we performed a meta-analysis of published data that measured the concentrations of, topically applied, antimicrobials in the cornea or aqueous humour. We then correlated these values with the in vitro minimum inhibitory concentration (MIC). Methods and AnalysisWe searched PubMed to identify studies reporting aqueous and/or corneal concentrations of 53 topically applied ocular antimicrobials, spanning the following classes: beta-lactams, glycopeptides, aminoglycosides, chloramphenicol, lincosamides, macrolides, oxazolidinones, steroidal antimicrobials, tetracyclines, diaminopyrimidines, sulfonamides, lipopeptides and polymyxins. For each class, two clinicians independently screened the abstracts. For articles that met the inclusion criteria, data were extracted on participant species, antimicrobial concentration, dosing regimens, epithelial status, and measurement methods. Concentrations were standardised to mg/L. First quartile concentrations (EQ1) were extrapolated from the mean and standard deviation or calculated from the contained data where available. The data were tabulated to generate the EQ1 concentrations for the aqueous and cornea of each antimicrobial, stratified by applied concentration and dosing regimen. ResultsWe screened 7247 publications. Eighty-one publications were included in the meta-analysis, comprising data on the aqueous and/or corneal concentrations of twenty-eight antimicrobials. Bioassay was the most frequently used method for quantifying antimicrobial concentrations (25 studies), followed by liquid chromatography and fluorescence assays (18 studies each), mass spectrometry (12 studies), and radioactivity and colorimetric assays (three studies each). ConclusionWe provide a practical resource for clinicians to assess whether the expected EQ1 of an antimicrobial in the cornea is above the in vitro MIC of the pathogen. This reduces reliance on systemic break-point concentrations enabling evidence-based antimicrobial treatment decisions for microbial keratitis. KEY MESSAGESO_ST_ABSWhat is already known on the topicC_ST_ABSMicrobial keratitis (MK) is a major cause of preventable blindness worldwide. The susceptibility of an isolate is based on systemic breakpoint criteria that may not reflect corneal or aqueous concentrations following topical application. What this study addsWe provide a comprehensive and standardised resource of corneal and aqueous antimicrobial concentrations following topical application. This enables treatment decisions based on the minimal inhibitory concentrations (MIC) of the isolate and the expected tissue concentration of the antimicrobial for evidence-based management of MK. How this study might affect research, practice or policyThis study provides a practical resource linking in vitro antimicrobial MIC values to anticipated ocular drug concentrations, enabling more precise treatment of microbial keratitis, supporting research and the development of clinical guidelines.

PurposeEvaluating 12-month visual and anatomical outcomes after switching to faricimab in diabetic macular oedema (DMO) patients with sub-optimal response to aflibercept 2mg. Patients and methodsSixty-two eyes of fifty patients were enrolled in this retrospective study at a UK tertiary referral centre. This consisted of DMO patients with sub-optimal response to aflibercept 2mg who were switched to faricimab. Four loading injections of faricimab were given at monthly intervals, followed by a treat-and-extend regime. The sub-optimal response was defined as CST >325 microns or >20% from best CST despite aflibercept 2mg at less than or equal to 8 weekly intervals([&le;]q8w) having completed a loading dose of aflibercept 2 mg (6 injections at monthly intervals). Outcome measures were best-recorded visual acuity (BRVA), central subfield thickness (CST), and treatment intervals. ResultsBaseline BRVA was 67.6 ({+/-}11.8) letters and CST was 406.4 ({+/-}105.9) {micro}m, and the mean treatment interval was 6.5 ({+/-}1.8) weeks. At baseline, 24.2% of eyes were treated every 4 weeks (q4w), 19.4% every 6 weeks (q6w), and 56.5% every 8 weeks (q8w). After the 4th faricimab loading dose, 54 patients continued on treat-and-extend faricimab. BRVA improved to 70.4 ({+/-}12.7) letters (p=0.007) while CST reduced to 372.8 ({+/-}132.0){micro}m (p=0.070). The mean injection interval improved to 7.4 ({+/-}2.6), 95%CI[0.1, 2.9]weeks. Subjects were followed up for 57.1 ({+/-}19.7) weeks, with a mean of 7.92 ({+/-}2.53) faricimab injections. At the latest follow-up, BRVA was stable at 68.7 ({+/-}14.6)(p=0.918) letters. CST had reduced further to 343.1 ({+/-}117.5) {micro}m(p=0.034). Treatment intervals at the latest follow-up were: 3.2% q4w, 9.7% q6w, 30.6% q8w, 3.2% q10w, 11.3% q12w, 1.6% q14w, 6.5% q16w, with 53.2% on [&ge;]q8w. The mean injection interval had also improved to 9.2 ({+/-}3.1) weeks(p=0.122). ConclusionIn this study, DMO patients with sub-optimal response to aflibercept 2mg experienced improved anatomical outcomes and extended treatment intervals while maintaining vision by switching to faricimab.

PurposeThe aim of this clinical investigation was to evaluate the safety and effectiveness of iota-carrageenan (I-C) eye drops in the treatment of mild-to-moderate dry eye disease (DED). MethodsIn this prospective, single arm, open label clinical investigation, thirty adult participants with mild-to-moderate DED applied I-C eye drops three times daily for four weeks. Before start and after end of treatment, participants rated DED symptoms (foreign body sensation, burning/stinging, itching, pain, sticky feeling, blurred vision and photophobia), both after exposure to a normal controlled environment (NCE) and to an adverse controlled environment (ACE). Additional endpoints were changes in ocular surface disease index (OSDI), Change in Dry Eye Symptoms Questionnaire (CDES-Q), corneal and conjunctival surface damage, tear film break-up time, tear evaporation and production. Tolerability was assessed by participants at start and end of treatment. Safety, including visual acuity and intraocular pressure, was monitored throughout the investigation. ResultsAfter four weeks of treatment with I-C eye drops, the mean total DED score after ACE was significantly reduced by -11.89 points (95% CI: -15.11, -8.67), p<0.001. The mean score reduction between baseline and final visit after NCE was slightly less pronounced, with -8.07 points (95% CI: -10.71; -5.43), p<0.001. The vast majority of participants (93% after ACE and 89% after NCE exposure) recorded a reduction in total DED score between baseline and final visit. Mean OSDI score significantly decreased by -7.75 points (95% CI: -10.85, -4.63), p<0.001. ACE-induced deterioration of tear film stability as well as corneal and conjunctival damage were reduced following treatment. All adverse events were mild and transient in nature. 93% of the patients described I-C eye drops as well or very well tolerated. Treatment did not negatively impact any of the safety parameters. ConclusionI-C eye drops are effective, safe and well tolerated. Treatment with I-C eye drops alleviates DED symptoms, stabilizes tear film and protects the ocular surface in patients with mild-to-moderate DED even under adverse environmental conditions. Trial RegistrationNCT06262100.

ObjectiveThis study aimed to evaluate the incidence, patterns, and determinants of ocular hypertension (OH) following Bevacizumab Intravitreal injections for various retinal diseases at KCMC Hospital, Tanzania. MethodsA prospective cohort study was conducted from August 2023 to July 2024, involving 120 participants. OH was defined as an intraocular pressure (IOP) >21 mmHg or an increase >5 mmHg from baseline. Data on demographics, injection history, ocular conditions, and systemic factors were collected. IOP was measured at baseline, immediately post-injection, and at six-week intervals during follow-up. Paired t-tests compared mean IOP differences, Nelson Allan estimator curves assessed cumulative OH risk, and Poisson regression identified associated factors. ResultsParticipants median age was 62 years, with diabetic macular edema (52.5%) being the most common indication. OH incidence was 15%, significantly associated with the number of injections (adjusted hazard ratio [AHR] 2.17, 95% CI 1.56-3.16, p < 0.001) and history of YAG laser capsulotomy (AHR 0.33, 95% CI 0.12-0.88, p = 0.028). Temporary post-injection IOP spikes normalized within 60 minutes. ConclusionThe study revealed a higher incidence of ocular hypertension following Bevacizumab injections compared to other studies. Significant factors included injection frequency and a history of YAG laser capsulotomy, with repeated injections leading to delayed normalization of intraocular pressure and increased spikes during subsequent visits.

BackgroundNeovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) represent the leading causes of vision impairment and blindness among the elderly population and people with diabetes, respectively. To reduce disease burden and improve disease management, highly effective therapies and optimal treatment are of major importance. In September 2022, faricimab was approved for the treatment of nAMD and DME in Germany, allowing a treatment approach with dual Ang-2/VEGF-inhibition. This research project was conducted to investigate the clinical care and therapeutic practice in German nAMD and DME patients. Furthermore, by evaluating upload patterns in real-world practice, this study aimed to assess the use of faricimab in treatment-naive patients who received faricimab as a first-line treatment at these centers. Data on visual acuity and drying of the retina was collected in a descriptive manner. MethodsZEUS is a multicenter retrospective analysis of anonymized routinely collected data on patients with nAMD or DME who have been treated with intravitreal injections (IVT) between October 2022 and September 2024. A total of 24 sites (ophthalmologic practices or centers) across Germany reported predominant IVT regimen, drug upload strategies and diagnostic imaging techniques used in the routine care of patients with nAMD and DME in an electronic case report form (eCRF). For the subset of IVT injection-naive patients receiving faricimab data were extracted from patient charts and entered in an anonymized aggregated form into eCRF. Analysis included proportion of IVT injection-naive patients treated with faricimab in first-line, baseline characteristics of these patients/eyes, and reduction of fluid in the macula and changes in visual acuity during faricimab upload phase. ResultsThe majority of sites (62.5%) applied a treat-and-extent (T&E) regimen, regardless of the chosen IVT. In case of faricimab the predominant upload scheme was 4 injections applied by 50% of sites, compared to three injections for other IVTs (58.3%) depending on the disease (nAMD/DME). OCT displayed the standard diagnostic at all sites (100.0%), other diagnostic procedures such as fluorescein angiography (FA, 62.5%) and OCT-A (25%) were applied less often. Out of the 24 sites, more than half initiated faricimab as first-line therapy in [&ge;]20% of patients. More than 20% achieved a CRT reduction of either 40-60%, 20-40% or 0-20% during faricimab upload; a reduction of more than 80% was achieved in 14.4% of nAMD eyes. The majority of DME eyes (43.9%) displayed a CRT reduction of 20-40%. In the faricimab upload phase, absence of IRF was achieved in 67.2% of nAMD eyes, while an absence of only SRF and both IRF and SRF was seen in 65.0% and 56.7% of eyes. Approximately 80% of DME eyes were free of SRF in the upload phase. The main reason for using faricimab as first-line therapy was to achieve an increase in injection intervals and best effectiveness. Discontinuation rates were low. ConclusionThis is the first analysis of general nAMD and DME treatment modalities as well as real-world effectiveness of faricimab in a large cohort of treatment-naive patients in Germany. Sites prefer individual approaches based on patients needs. First-line treatment with faricimab resulted in visual acuity gain during the faricimab upload phase in a real-world setting. These findings may help to better understand treatment strategies and first-line use of faricimab in nAMD and DME in Germany.

IntroductionOcular surface disorders are prevalent, impacting millions worldwide and causing significant morbidity. Conventional treatments often fall short in addressing refractory cases. Topical insulin has emerged as a potential therapeutic option. ObjectiveThis systematic review aimed to evaluate the safety and efficacy of topical insulin for ocular diseases. MethodsWe conducted a systematic review in major databases including the PubMed, MEDLINE, and EMBASE for studies published from (1976 Jan - 2024 Feb) investigating topical insulin for ocular conditions. Studies were screened and selected based on predefined inclusion/exclusion criteria. Data on safety and efficacy were extracted and analyzed. ResultsTen studies (1 case-control, 3 randomized prospective, 3 retrospective, and 3 double-blind designs) met the inclusion criteria. Studies explored various indications, including neurotrophic corneal ulcers, persistent epithelial defects, recurrent epithelial erosions, dry eye disease, and postoperative corneal wound healing in diabetic patients. Overall, findings suggested promising outcomes with topical insulin: promoting healing of refractory neurotrophic corneal ulcers, accelerating reepithelialization in persistent epithelial defects, reducing recurrence of recurrent epithelial erosions, improving symptoms and reducing corneal staining in dry eye disease, enhancing postoperative corneal epithelial wound healing in diabetic patients. Adverse events were minimal and primarily reported as transient stinging or discomfort. ConclusionThis review provides encouraging evidence for the therapeutic potential of topical insulin in diverse ocular diseases. While methodological limitations exist, particularly in non-randomized studies, the current body of literature suggests topical insulin may offer a safe and effective treatment option for patients with refractory corneal disorders.

AimsPrimary objective: To determine the minimum inhibitory concentration (MIC) of key antifungal drugs (natamycin, amphotericin B, voriconazole and econazole) against fungal isolates cultured from fungal keratitis patients in South India. Secondary objective: to ascertain correlations between antifungal resistance and patient outcome. MethodsIn this prospective observational study, MIC values were determined for fungal isolates cultured from 153 patients, with samples collected between May - August 2025. Clinical characteristics were collected at baseline, one-week and one-month following enrolment to the study. Mean antifungal MIC per fungi genera were compared. Statistical differences in MIC and patient characteristics were determined via multiple logistic or linear regression. Significance for participant outcome against resistant/non-resistant fungi were determined by Fishers exact test. ResultsResistance of Fusarium spp. isolates to: natamycin: 38.3%; amphotericin B: 93.8%; voriconazole: 97.5% and econazole: 76.5%. Resistance of Aspergillus spp. isolates to: natamycin: 66.7%; amphotericin B: 87.9%; voriconazole: 6.1%; and none were resistant to econazole. Natamycin MIC correlated with worse baseline (P[&le;]0.01) and one-week (P[&le;]0.05) visual acuity and ulcer severity. Poor patient outcomes (non-healing or therapeutic keratoplasty) were elevated 6.5x where the infection was caused by natamycin resistant Aspergillus, compared to sensitive Aspergillus strains (P[&le;]0.05). ConclusionThe majority of fungal isolates were resistant to multiple antifungals, none of the Fusarium isolates were sensitive to all four drugs, and 15% were resistant to all four drugs. Aspergillus isolates had high levels of resistance to the polyenes, but remained largely susceptible to the azoles. Overall, worse patient outcomes were associated with increased natamycin MIC. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSFungal keratitis is a major cause of blindness worldwide, disproportionately affecting those across the tropics, with incidence increasing across temperate climates. The majority of cases are caused by the filamentous fungi Fusarium spp. and Aspergillus spp.. Antifungal resistance is poorly characterised in fungal keratitis. What this study addsWe report the fungal aetiology and the minimum inhibitory concentration (MIC) against natamycin, amphotericin B, voriconazole and econazole of isolates cultured from 153 patient corneal scrape samples between May - August 2025 at a South Indian hospital. We found high levels of fungal resistance, with Fusarium isolates having high levels of resistance to both polyenes and azoles. Aspergillus isolates showed good azole sensitivity, but high levels of resistance to polyenes. Aspergillus resistance to natamycin correlated with worse clinical outcomes at one-month. Natamycin resistance contributed to worse visual acuity and ulcer severity at baseline and one-week follow-up across all fungi. How this study might affect research, practice or policyOur study confirmed that natamycin was best available first-line treatment for Fusarium. Aspergillus isolates were mostly resistant to natamycin and amphotericin B, and this impacted patient outcomes. SynopsisWe identified high incidence of multi-drug resistant fungi, and that patients were more likely to have a poor clinical outcome if the fungal isolate was resistant to natamycin. This was most pronounced for Aspergillus isolates.

BackgroundDiabetic macular oedema (DME) is a vision-threatening complication of diabetes mellitus. It is reliably detected using optical coherence tomography (OCT). This work evaluates a deep learning system (DLS) for the automated detection and classification of DME severity from OCT images. MethodsAnonymised OCT images were retrospectively obtained from 950 patients at University Hospital Galway, Ireland. Images were graded by a consultant ophthalmologist to classify the level of DME present (normal, non-centre-involving DME, centre-involving DME) excluding other pathologies. A DLS was trained using cross-validation, then evaluated on a test dataset and an external dataset. The test set was graded by a second ophthalmologist for comparison. ResultsIn detecting the presence of DME, the DLS achieved a mean area under the receiver operating characteristic curve (AUC) of 0.98 on cross-validation. AUCs of 0.94 (95% CI 0.90-0.98) and 0.94 (0.92-0.96) were achieved on evaluation of DME detection for the test dataset when graded by the first and second ophthalmologist respectively. An AUC of 0.94 (0.92-0.96) was achieved on evaluation with the external dataset. When detecting the DME severity, AUCs of 0.98, 0.86 and 0.99 were achieved per class on cross validation. For the test dataset, AUCs of 0.99, 0.89 and 0.98 were achieved when graded by the first ophthalmologist and AUCs of 0.96, 0.89 and 0.95 were achieved when graded by the second ophthalmologist. ConclusionThis study suggests promising results for the use of deep learning in the classification of severity of DME which could be used to automate screening for DME and direct appropriate referrals.

BackgroundThis systematic review and meta-analysis aim to evaluate the efficacy and safety of the PAUL(R) Glaucoma Implant in reducing intraocular pressure and number of anti-glaucoma medication use in both adult and paediatric populations. MethodsA systematic review was conducted following the PRISMA guidelines. The databases PubMed, Ovid-Embase and Scopus were searched to include studies published between January 2017 and September 2025. Studies were stratified by age and risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and ROBUST-RCT for randomized trials. Primary outcomes were intraocular pressures and number of glaucoma medications at each follow-up visits. Random effects meta-analyses were performed. Secondary outcome was complications. ResultsTwenty-four studies (twenty adults, four paediatric) comprising 836 eyes were included in our review and meta-analysis. Both adult and paediatric patients showed significant IOP reduction post-surgery, with a mean difference of 17.48 mmHg (95% CI: 14.59, 20.37) and 20.31 mmHg (95% CI: 7.80, 32.82) at 1 week, respectively, and sustained reductions at 12 months. The reduction in glaucoma medications was 79.2% for adults and 71.4% for children at 12 months. Subgroup analyses demonstrated greater IOP reduction in studies conducted in the Middle East. The uses of Mitomycin C did not significantly affect outcomes. ConclusionThe PAUL(R) glaucoma implant showed significant and sustained IOP reductions with reduced need for glaucoma medications. The PAUL(R) glaucoma implant is a promising surgical option for glaucoma management in both adults and children. Further long-term prospective comparative studies are needed to assess long-term efficacies and allow direct comparisons with other glaucoma drainage devices.

PurposeOcular vascular diseases are common causes of visual impairment and blindness, for which intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) is the first-line therapy. Current study describes the profile of patients receiving intravitreal anti-VEGF injections in Bhutan. This is the first study of its kind to inform the national health policy. MethodsFor this retrospective study, we reviewed the surgical registers of the vitreoretinal unit across Bhutan over three years. Patient demography, clinical findings, diagnostic tests performed, and diagnoses or indications for intravitreal anti-VEGF injections were logged. A descriptive analysis was performed. ResultsA total of 381 patients received intravitreal anti-VEGF injections in the operating theatres as mandated by the national guidelines. The majority of patients were males (230, 60.4%). The mean age was 65.2 {+/-} 13.5 years, ranging from 13 to 90 years, and a median of 69 years. Majority of the treated eyes (117, 30.7%) had BCVA <3/60 to light perception (PL), and another 51 eyes (13.4%) had < 6/60 to 3/60. The most common indication for anti-VEGF injection was neovascular AMD (168 cases, 42.2%), followed by retinal vein occlusion (132 cases, 34.6%), diabetic macular oedema and retinopathy (50 cases, 13.1%), and myopic choroidal neovascular membrane (11 cases, 0.03%). ConclusionsBhutan faces both economic and geographic challenges, on top of limited human resources for managing vitreoretinal diseases. With an ever-increasing load of vitreoretinal diseases, and systemic diseases like diabetes and hypertension, there is a need to improve vitreoretinal services. Regular vitreoretinal services are provided only at the national referral hospital located in the north-west. For successful management, an effective community screening program, right referrals, and proper transport facilities must go hand-in-hand, and or extend regular vitreoretinal services to regional referral hospitals.

ObjectiveThis study aims to assess the incidence, types, and associated risk factors of postoperative complications following cataract surgery at Kilimanjaro Christian Medical Centre (KCMC) from 2023 to 2024 BackgroundCataracts remain a leading cause of blindness globally, with disproportionate burdens in low-resource settings. Despite advancements in surgical techniques like phacoemulsification (PHACO), extracapsular cataract extraction (ECCE) remains widely used in sub-Saharan Africa. Limited data exist on postoperative complications and comparative outcomes in Tanzania. MethodsA prospective cohort study was conducted at Kilimanjaro Christian Medical Centre (August 2023-July 2024) involving 308 adults undergoing ECCE or PHACO. Participants were followed for six months postoperatively. Primary outcomes included visual acuity (VA) and complications (e.g., corneal edema, raised intraocular pressure [IOP]). Multivariable logistic regression identified risk factors for poor outcomes. ResultsThe cohort (median age: 68 years; 51.6% male) underwent ECCE (65.3%) or PHACO (34.7%). PHACO demonstrated superior outcomes: patients undergoing ECCE had 2.5-fold higher odds of poor VA (adjusted OR: 2.4, 95% CI: 1.21-5.01, p=0.013) and 34% higher complication risk (adjusted RR: 0.66, 95% CI: 0.50-0.88, p=0.004). Complications occurred in 58.8%, primarily corneal edema (40.6%) and posterior capsular opacity (38%). Specialist-performed surgeries reduced complications by 62% versus trainees (p<0.001). ConclusionPHACO outperformed ECCE in visual outcomes and safety, with specialist expertise further reducing risks. Findings support prioritizing PHACO adoption, enhancing surgical training, and standardizing postoperative care in resource-limited settings. Multicenter randomized trials are needed to validate these results.

ObjectiveVision impairment represents a growing burden to society and training protocols related to low vision rehabilitation (vision rehab) vary across ophthalmology residency programs. We surveyed practicing ophthalmologists regarding their vision rehab knowledge, confidence levels, and referral thresholds. We categorized subjects and compared response patterns between groups. DesignProspective observational Subjects185 practicing ophthalmologists MethodsWe created an Ophthalmology Low Vision Questionnaire and administered it to all enrolled subjects via email. We categorized subjects based on duration of practice, subspecialty area, and exposure to vision rehab during residency training. We drew conclusions by comparing responses between various subject categories. Main Outcome MeasuresThe primary outcome measure was comparison of confidence levels and thresholds for vision rehab referral across groups. We used statistical tests to look for associations between practice duration, subspecialty area, vision rehab exposure during residency, and referral patterns. ResultsOphthalmologists practicing for 6 or less years were more likely to have had a formal vision rehab rotation during their residency training compared to ophthalmologists practicing for 7 or more years (P = 0.03). Ophthalmologists who completed a formal vision rehab rotation during residency reported greater confidence in their ability to appropriately identify patients who could benefit from vision rehab referral (P = 0.04) and referred patients at earlier visual acuity thresholds (P = 0.04). Clinical subspecialty did not have a significant effect on vision rehab referral confidence or thresholds. ConclusionsVision rehab rotations during residency lead to improved referral confidence and earlier referral for these vital services. Standardization of vision rehab exposure across ophthalmology residency programs can help to improve outcomes for visually impaired patients.

AimTo capture the direct and indirect cost estimates of dry eye disease (DED), stratified by disease severity, in patients from Canada and to understand the impact of DED on quality of life (QoL) in this group. MethodsA prospective, multi-centre, observational, cross-sectional study was conducted at six optometry and ophthalmology sites across Canada. Eligible patients completed a 20-minute survey on demography, general health, disease severity, QoL, and direct and indirect costs. ResultsA total of 151 patients participated in the study and 146 were included in the analysis. Mean (standard deviation [SD]) age was 49.8 (11.4) years and most patients were female (89.7%). DED was considered moderate or severe by 19.2% and 69.2% of patients, respectively. Sjogrens syndrome was reported by 8.2% of patients. Total mean annual costs of DED were $24,331 (Canadian dollars [CAD]) per patient and increased with disease severity. Mean (SD) indirect costs for mild, moderate, and severe disease were $5,961 ($6,275), $16,525 ($11,607), and $25,485 ($22,879), respectively. Mean (SD) direct costs were $958 ($1,216), $1,303 ($1,574), and $2,766 ($7,161), respectively. QoL scores were lowest in patients with Sjogrens syndrome and those with severe DED. ConclusionsThis study provides important insights into the negative impact of DED in a Canadian setting. Patients with severe DED reported higher direct and indirect costs and lower QoL compared with those with mild or moderate disease. Increased costs and poorer QoL were also evident for patients with DED plus Sjogrens syndrome versus DED alone.

PurposeTo investigate the epidemiology of post-injection endophthalmitis (PIE) and evaluate the association of sociodemographic and clinical factors with incidence, timing of onset, and presenting visual acuity (VA) using the IRIS(R) Registry (Intelligent Research in Sight). DesignRetrospective cohort study. ParticipantsPatients with endophthalmitis after an intravitreal anti-VEGF injection in the IRIS(R) Registry from 2016-2023. MethodsOnly the first anti-VEGF injection per eye was included. Exclusion criteria were cataract surgery during the study, intravitreal corticosteroids within 30 days prior to PIE, uveitis, or cystoid macular edema. Mean best VA was recorded within 100 days prior to anti-VEGF treatment and at the time of PIE. Regression modeling evaluated associations between endophthalmitis and sociodemographic and clinical factors, and time to PIE. Linear regression assessed predictors of VA at the time of PIE, and descriptive statistics were used to analyze time to onset. Main Outcome MeasuresIncidence of post-injection endophthalmitis, time to symptom onset, and best VA at diagnosis. ResultsAmong 1,025,788 eyes treated, 600 (0.059%) developed endophthalmitis. Key risk factors included residence in U.S. territories (OR = 2.62; P = 0.038 vs. Northeast) and history of intravitreal corticosteroid injection (OR = 2.35; P = 0.004 vs. no history). The strongest protective factor was non-smoking (OR = 0.71; P = 0.023 vs. smokers). The median time from injection to onset of PIE was 5 days (interquartile range [IQR]: 3-8). The salient predictors of time to PIE included patient age (4.3 days sooner per decade older; P = 0.04), prior corticosteroid treatment (11.7 days sooner; P = 0.02), and a diagnosis of diabetic retinopathy (2.3 days sooner; P=0.03). Baseline VA before PIE was the only significant predictor of VA at the time of PIE diagnosis (0.67, P < 0.001). ConclusionPost-injection endophthalmitis was significantly associated with residence in U.S. territories and prior intravitreal corticosteroid exposure, while non-smoking status was protective. Most cases presented 3-8 days following anti-VEGF injection. Older age, history of prior corticosteroid treatment, and diabetic retinopathy were associated with earlier PIE. Baseline VA predicted VA at the time of PIE.

BackgroundThe management of macular edema and ocular neovascularization is changing and includes a new group of drugs called anti-vascular endothelial growth factor (anti-VEGF). Intra-vitreal injection of anti-VEGF agents has become the new standard of care for macular edema. However, data on their real world effectiveness and safety of these drugs in African eye care settings are very scarce. ObjectiveTo assess the visual outcome of intravitreal Avastin (IVA) injection at University of Gondar hospital tertiary eye-care and training center. MethodsA retrospective analysis of medical records of patients who received IVA at the center was done. The main outcome measure was visual acuity (VA). ResultsThe study included 37 eyes of 34 study participants with macular edema secondary to diabetic retinopathy, retinal vein occlusions, and neovascular age related macular degeneration (AMD). Mean VA improved from 6/60 (approximate 35 ETDRS letters) at baseline to 6/24 (approximate 55 ETDRS letters) at 2 months follow-up (p=0.0045) and this improvement was maintained at 6 months of follow up. This happened after mean injection of 2.5 times per eye over 6 months period. No major ocular or systemic treatment related adverse events were observed. ConclusionPatients who received IVA as initial therapy for macular edema from diabetic retinopathy, retinal vein occlusions, and neovascular AMD has a significant mean VA improvement which was maintained up to 6 months. Short term results show that IVA is effective and safe.

ImportanceDiabetic retinopathy (DR) progression significantly impacts vision and quality of life in patients with Type 2 Diabetes Mellitus (T2DM). Statins and fibrates are commonly prescribed lipid-lowering medications, but their comparative effectiveness in DR progression remains uncertain. ObjectiveTo determine whether fibrates reduce the risk of DR progression compared to statins in patients with T2DM and nonproliferative diabetic retinopathy (NPDR). Design, Setting, and ParticipantsRetrospective cohort study using the TriNetX Global Collaborative Network, a multicentered, population-based electronic medical record database. Inclusion criteria consisted of patients diagnosed with T2DM and NPDR 5-20 years prior. Patients were propensity score matched based on demographics and comorbidities. Two cohorts were defined: patients on fibrates but not statins (n = 543), and patients on statins but not fibrates (n = 60,135). After matching, each cohort included 542 patients. Main Outcomes and MeasuresPrimary outcomes: intravitreal antiVEGF injection or retinal laser procedures Secondary outcomes: progression to PDR, vitreous hemorrhage (VH), neovascularization (NV), or tractional retinal detachment (TRD) Tertiary outcomes: neovascular glaucoma (NVG) or pars plana vitrectomy (PPV). ResultsFibrate-treated patients had a 57.3% risk reduction in anti-VEGF injection (RR = 0.427; 95% CI: 0.219, 0.830; p < 0.011) and longer time-to-injection (log-rank x2 = 4.927; p < 0.027). PDR risk was reduced by 59.3% (RR = 0.407; 95% CI: 0.242, 0.684; p < 0.001) with delayed progression (log-rank x2 = 8.657; p < 0.004). Fibrate use was associated with 72.1% lower instantaneous risk of NGV (HR = 0.279; 95% CI: 0.079, 0.991, p < 0.015) and delayed onset (log-rank x2 = 4.448, p < 0.036) despite a higher survival probability in the statin group (97.08% vs 96.65%). Fibrates lowered the absolute risk of NV (-0.019; 95% CI: -0.030, -0.007; p < 0.002) but increased risk of TRD (0.018; 95% CI: 0.007, 0.030; p < 0.003); however, neither occurred in the comparison group, limiting statistical power. Conclusions and RelevanceAmong patients with T2DM and NPDR, fibrates were associated with reduced risk of antiVEGF injection, PDR progression, and NVG onset compared to statins. These findings suggest fibrates may help mitigate DR progression.