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Intravitreal injections (IVIs) are the most common outpatient procedure worldwide, yet no consensus exists regarding their optimal setting. This study analysed 101 976 IVIs performed between 2017 and 2023, comparing endophthalmitis rates before and after introducing a mobile laminar air flow (LAF) device in a clean room. The incidence of endophthalmitis decreased from 0.033% to 0.013%, a 63.2% risk reduction (Odds Ratio=0.368, p=0.04). These findings suggest that mobile LAF enhances air quality and reduces infection risk, offering a cost-effective, efficient alternative to operating theatres for IVIs.

AimsTo explore the clinical application of a novel swept-source anterior segment optical coherence tomography angiography (AS-OCTA) system for imaging corneal neovascularisation (CoNV), assessing limbal vasculature and detecting short-term vascular changes following pharmacologic vasoconstriction.MethodsThis cross-sectional observational study included 20 eyes: 10 with clinically diagnosed CoNV of various aetiologies and 10 healthy controls. Each eye underwent AS-OCTA imaging using the BMizar 400kHz Full-Range Swept-Source OCT system at baseline and after administration of 10% phenylephrine (PE). FlowArea (mm2) was automatically calculated across predefined circular regions of interest (ROIs) encompassing the cornea, limbus and episclera. In corneal and limbal ROIs, en face images were segmented into three depth layers: total (epithelium to endothelium), superficial (epithelium to 150 µm) and deep (150 µm to endothelium).ResultsCoNV eyes exhibited significantly higher total and deep corneal FlowArea compared with controls (p=0.0002 and p=0.0005, respectively). Post PE, a significant reduction in FlowArea was observed in the total and deep corneal layers of CoNV eyes (p=0.006 and p=0.009, respectively), and in the limbal region of both groups, with significant reductions observed in CoNV and controls (p=0.006 and p=0.003, respectively).ConclusionsThis AS-OCTA platform enabled high-resolution, depth-resolved visualization of CoNV and revealed vascular changes following topical vasoconstriction. The extended field of view allowed simultaneous assessment of corneal, limbal and episcleral vasculature within a single scan session, supporting its potential role in both diagnostic evaluation and longitudinal monitoring of anterior segment diseases.

AimTo interpret the likely clinical susceptibility of isolates from microbial keratitis (MK), 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).MethodsWe 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, sulphonamides, lipopeptides and polymyxins. Two clinicians independently screened the abstracts and extracted data from studies meeting the inclusion criteria, including participant species, antimicrobial concentration, dosing regimens, epithelial status and measurement methods. Concentrations were standardised to mg/L. The data were stratified by applied concentration, dosing regime and species. First quartile concentrations (EQ1) were extrapolated to provide a conservative estimate and tabulated practice resource for clinicians treating MK.ResultsWe screened 7247 publications. 81 publications were included in the meta-analysis, comprising data on the aqueous and/or corneal concentrations of 28 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 colourimetric assays (3 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. This enables standardised guidelines for evidence-based antimicrobial treatment decisions for MK.

Background/AimsTo evaluate the performance of an artificial intelligence (AI) model for detecting and monitoring microbial keratitis (MK) using anterior segment optical coherence tomography (AS-OCT).MethodsThis is a prospective observational study. Patients with clinically suspected MK and healthy participants were included. In addition to routine assessment and treatment with topical fluoroquinolone therapy, patients underwent AS-OCT at each clinic visit. These images were tested on our DeepLabV3 network-based AI model, which aims to diagnose and record changes to infiltrate sizes of MK lesions over time.ResultsThe AI model accurately captured MK lesions in 93% of cases (152/163). MK was not detected in scans from healthy eyes, and there were no cases of artefact being falsely detected. The model had a sensitivity of 93% (95% CI 88% to 97%), specificity of 100% (95% CI 88% to 100%), positive predictive value of 100% (95% CI 98% to 100%) and negative predictive value of 73% (95% CI 61% to 83%). Using only the corneal component with masking of the anterior chamber, the AI model showed agreement on change with both observers in 76% (13/18) cases.ConclusionsThis AI framework reliably identified MK lesions using AS-OCT, with high sensitivity and specificity. The framework was able to identify change in most cases compared with corneal specialists.

ObjectiveComparing definitions of progression in keratoconus (KC) patients after corneal cross-linking (CXL).MethodsRetrospective case series of KC eyes underwent CXL. Keratoconus progression after CXL treatment was defined based on either the widely accepted standard criteria (i.e., maximum keratometry (Kmax), increase >1 Diopter (D) or thinnest corneal thickness (ThCT) reduction >20 mm) or the ABCD progression criteria.ResultsThirty-seven KC eyes underwent CXL. Kmax showed a significant reduction from baseline values after CXL (p<0.01), while no difference in ThCT (p=0.12) and in CDVA (p=0.1) was found. Applying standard criteria for progression 18.9% (7/37) of eyes were classified as progressed and 43.2% (16/37) according to the ABCD method.ConclusionsDifferent definition of progression leads to increased misclassification, there is a need of a shared protocol to assess the effectiveness of CXL.

PurposeTo assess the influence of preoperative stromal hyperreflectivity on visual outcomes of Descemet Membrane Endothelial Keratoplasty (DMEK) surgery.DesignMonocentric, cohort study.MethodsAnterior Segment Optical Coherence Tomography (AS-OCT) imaging of eyes which underwent uncomplicated DMEK surgery at the Royal Liverpool University Hospital were collected before and after surgery. Patient electronic records were reviewed to collect visual acuity outcomes. A deep-learning algorithm was developed to segment the corneal boundaries and identify clusters of hyperreflectivity. The loss function utilised in this study was a combination of dice loss and cross-entropy loss and an Adam-based optimizer was employed for optimisation.ResultsA total of 19 eyes from 18 patients were analysed. Visual acuity improved in all eyes after DMEK (mean [SD], 0.59 [0.31] vs. 0.26 [0.22] LogMAR, p<0.001). Stromal hyperreflectivity correlated with preoperative central corneal thickness (p=0.88, p<0.001) but not with preoperative visual acuity (p=0.11, p=0.65). At 6 months after DMEK surgery, patients with preoperative stromal hyperreflectivity higher than the median values had lower final visual acuity than those with lower values of stromal hyperreflectivity (mean [SD], 0.29 [0.3] vs. 0.23 [0.12] LogMAR, p<0.04).ConclusionsClusters of stromal hyperreflectivity can be identified and monitored with deep-learning based segmentation algorithms. Preoperative stromal hyperreflectivity was associated with lower visual acuity recovery after DMEK surgery. Tools to identify stromal hyperreflectivity corresponding to clinical stromal scarring can help clinicians in stratifying candidate patients for DMEK and gauging the expected visual acuity recovery rate.

ObjectiveTo evaluate the Descemet membrane endothelial keratoplasty (DMEK) preparation performance of trainee surgeons in an ex vivo human donor cornea DMEK wet lab simulation setting.MethodsHuman donor corneoscleral rims unsuitable for transplantation were obtained from Moorfields Lions Eye Bank. At the wet lab, graft stripping was performed by scoring the peripheral endothelium. The trypan blue positive cells (TBPC) and cell density (cells/mm2—reticule count) were counted manually before and after stripping. The procedural time, peripheral and central tears and complete peel-off were also recorded and analysed.ResultsEight trainee surgeons attended the wet lab each attempting three DMEKs. Between the first and last attempts a significant decrease was seen in the procedural time (17.6 min vs 10.6 min (p<0.05)) and the TBPC % (12.9% vs 3.8% (p<0.05)). The percentage of tears peripherally and centrally also reduced between the first and the last trials (50% vs 13% (p=0.2226) and 38% vs 0% (p=0.1327)). A significant correlation was found between longer peeling times and higher TBPC % (p<0.001) with a 0.7% endothelial mortality increase for each additional minute required to complete the peel.ConclusionsDMEK wet labs provide a controlled risk-free learning opportunity for trainee surgeons to improve confidence and competence. Wet labs improve the success rate of DMEK graft preparation as well as flatten the learning curve. This emphasises the importance of continued support for the expansion of this valuable learning resource, promoting wider uptake of DMEK surgery.

IntroductionThe success of keratoplasty strongly depends on the health status of the transplanted endothelial cells. Donor corneal tissues are routinely screened for endothelial damage before shipment; however, surgical teams have currently no means of assessing the overall viability of corneal endothelium immediately prior to transplantation. The aim of this study is to validate a preoperative method of evaluating the endothelial health of donor corneal tissues, to assess the proportion of tissues deemed suitable for transplantation by the surgeons and to prospectively record the clinical outcomes of a cohort of patients undergoing keratoplasty in relation to preoperatively defined endothelial viability.Methods and analysisIn this multicentre cohort study, consecutive patients undergoing keratoplasty (perforating keratoplasty, Descemet stripping automated endothelial keratoplasty (DSAEK), ultra-thin DSAEK (UT-DSAEK) or Descemet membrane endothelial keratoplasty) will be enrolled and followed-up for 1 year. Before transplantation, the endothelial viability of the donor corneal tissue will be evaluated preoperatively through trypan blue staining and custom image analysis to estimate the overall percentage of trypan blue-positive areas (TBPAs), a proxy of endothelial damage. Functional and structural outcomes at the end of the follow-up will be correlated with preoperatively assessed TBPA values.Ethics and disseminationThe protocol will be reviewed by the ethical committees of participating centres, with the sponsor centre issuing the final definitive approval. The results will be disseminated on ClinicalTrials.gov, at national and international conferences, by partner patient groups and in open access, peer-reviewed journals.Trial registration numberNCT05847387.

Background: To compare four different optical coherence tomography (OCT) devices for visualization of retinal and subretinal layers in highly myopic eyes. Methods: In this prospective, observational, cross-sectional study, consecutive patients with high myopia and control subjects were imaged by four OCT devices: Spectralis OCT2, PlexElite 2.0 100 kHz, PlexElite 2.0 200 kHz and the Canon Xephilio OCT-S1. The acquisition protocol for comparison consisted of single vertical and horizontal line scans centered on the fovea. Comparison between the devices in the extent of visible retina, presence of conjugate image or mirror artifacts, visibility of the sclerochoroidal interface and retrobulbar tissue. Results: 30 eyes with high myopia and 30 control subjects were analyzed. The visualized RPE length was significantly different between the OCT devices with Xephilio OCT-S1 imaging the largest extent (p < 0.0001). The proportion of eyes with conjugate image artifact was significantly higher with the Spectralis OCT (p < 0.0001), and lower with the PlexElite 200 kHz (p < 0.0001). No difference in visibility of the sclerochoroidal interface was noted among instruments. The retrobulbar tissue was visible in a higher proportion of eyes using swept-source PlexElite 100 kHz and 200 kHz (p < 0.007) compared to the other devices. Conclusions: In highly myopic eyes, the four OCT devices demonstrated significant differences in the extent of the retina imaged, in the prevalence of conjugate image artifact, and in the visualization of the retrobulbar tissue.

Background To compare the change in lesion area over 4 years of follow-up in eyes with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) agents using either a proactive or a reactive regimen in routine clinical practice. Methods This was a multicentre, retrospective comparative study. Totally, 202 treatment-naïve nAMD eyes (183 patients) received anti-VEGF therapy according to a proactive ( n  = 105) or reactive ( n  = 97) regimen. Eyes were included if they had received anti-VEGF injections for a period of at least 4 years and had baseline fluorescein angiography and annual optical coherence tomography (OCT) imaging. Two masked graders independently delineated the lesion’s margins from serial OCT images and growth rates were calculated. Results At baseline, the mean [SD] lesion area was 7.24 [5.6] mm 2 in the proactive group and 6.33 [4.8] mm 2 in the reactive group respectively ( p  = 0.22). After four years of treatment, the mean [SD] lesion area in the proactive group was 5.16 [4.5] mm 2 showing a significant reduction compared to the baseline ( p  < 0.001). By contrast, the mean [SD] lesion area kept expanding in the reactive group during the follow-up and was 9.24 [6.0] mm 2 at four years ( p  < 0.001). The lesion area at 4 years was significantly influenced by treatment regimen, baseline lesion area, and proportion of visits with active lesions. Conclusions Eyes treated using a reactive strategy had an increased lesion area and worse visual outcomes at 4 years. By contrast, the proactive regimen was associated with fewer recurrences of active disease, shrinkage of the lesion area, and better vision at four years.