With the development of optical coherence tomography (OCT), subtle changes in the posterior vitreous can be observed that are not clearly visible by slit lamp biomicroscopy. With the advent of swept-source OCT (SS-OCT) technology in particular, variations in normal changes can now be visualised, as well as those associated with ageing.

In most normal eyes, the premacular lacuna and connected Cloquet’s canal can be clearly detected by SS-OCT (

). However, these structures become less noticeable with advancing patient age. The contours of the premacular lacuna collapse, and the liquefaction of the vitreous gel progresses.

In cases in which the premacular lacuna and Cloquet’s canal are not visible (

) and in which advanced vitreous liquefaction is present, a presumed bursa premacularis/posterior pre-cortical vitreous pocket (PPVP) appears (

Occasionally, the premacular lacuna and bursa fuse into a large empty space (

Differentiation of the premacular lacuna and the bursa premacularis/PPVP is important. Early studies found that the bursa premacularis/PPVP is a liquefied space with a relatively large volume, and not a thin space like the premacular lacuna.

In usual OCT examinations, the depth is emphasised (

, top) and the premacular lacuna looks relatively large. However, when viewing the premacular lacuna with vertical and horizontal scales on a 1:1 scale in young patients (

, bottom), the premacular lacuna is almost the same depth as the thickness of the retina.

The premacular lacuna seems to correspond to a sub-bursal space, referred to in one 

slit lamp microscopy study and later as an artefact.

 However, it is my opinion that the premacular lacuna corresponds to a sub-bursal space.

Details of the early phase of age-related posterior vitreous detachments (PVDs) were previously unknown because they were not visible by biomicroscopy, however, SS-OCT has furthered the understanding of these detachments.

Age-related PVD progression begins from the state of no PVD to the vicinity of the outer periphery of the macula, as seen in the OCT image on the upper left to lower left of 

 The PVD progresses throughout the posterior pole, but it is relatively rare for the condition to progress without showing an oval defect in the detached posterior vitreous cortex (

In many cases, the oval defect in the posterior vitreous cortex forms as shown in the middle or lower right, and the thin posterior vitreous cortex remains on the macular retina. There are two types of shallow PVD with an oval defect in the posterior vitreous cortex: one with vitreous gel attachment to the macula through the premacular oval defect of the posterior vitreous cortex (

 and one with no vitreous gel attachment to the macula (

The condition of vitreous attachment through the oval defect in the posterior vitreous cortex may be experienced during cre

ation of a PVD during vitreous surgery. This type of PVD is thought to provide protection for the fovea, where the retina is thin and fragile. The failure to make such a circular defect in the posterior vitreous cortex may induce the development of macular holes in some cases (

The structure that was defined as a bursa has many variations in ageing. When the bursa fuses with the premacular lacuna/ sub-bursal premacular space, it appears as a large empty space. There are some variations in PVDs starting in the posterior pole, but some of them are related to macular holes and epiretinal membranes, so detailed observation is indispensable.

Although these descriptions are based on my personal experience and opinion, I hope they increase clinicians’ understanding of vitreomacular interface diseases.

Dr Kakehashi is based at the Department of Ophthalmology, Saitama Medical Center, Jichi Medical University in Saitama, Japan. He has no financial interest in any aspect of this article.

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Kishi S, Shimizu K. Posterior precortical vitreous pocket. 

Worst JG. Posterior precortical vitreous pocket. 

Kakehashi A, Takezawa M, Akiba J. Classification of posterior vitreous detachment. 

Kakehashi A, Ishiko S, Konno S, et al. Observing the posterior vitreous by means of the scanning laser ophthalmoscope. 

Kakehashi A, Schepens CL, Trempe CL. Vitreomacular observations. I. Vitreomacular adhesion and hole in the premacular hyaloid. 

Articles

Understanding vitreomacular interface diseases is key to treatment.

The truth about invisible posterior vitreous structures

Although it is always important to consider optimising the ocular surface for all patients in order to improve their vision, it is of critical importance before cataract surgery. As has often been stated, cataract surgery is a form of refractive surgery. All our patients expect excellent postoperative results with clear and stable vision, regardless of the type of lens implant we are using.

I counsel my patients that an optimised ocular surface supports accurate preoperative measurements including refractions, keratometry, corneal topography and biometry, and that with a healthy tear film and smooth corneal surface, they can achieve their full visual potential.

On the other hand, a dry ocular surface with an increased tear break-up time, punctate staining or desiccation will affect the reliability, reproducibility and accuracy of the measurements—garbage in, garbage out. This increases the chances of the surgeon making an inappropriate IOL recommendation or selecting the wrong IOL power and the patient experiencing a suboptimal outcome. In fact, a poor ocular surface can have a profound effect on the corneal topography measurements.

Multifocal presbyopia-correcting lens implants offer patients the greatest chance for freedom from glasses after surgery; however, they are the most sensitive to ocular surface disease. This means that patients with significant dry eye who receive this IOL technology tend to have more variability in the quality of their vision than those who receive a monofocal or toric lens.

Furthermore, patients must be made aware that it is not enough to optimise their ocular surface before surgery; they must continue to take care of it postoperatively as well. If ocular surface disease recurs, vision will be adversely impacted.

No matter where patients are coming from—an outside referral or from within the practice—it is incumbent upon the surgeon to ensure their corneal health preoperatively. When I evaluate patients, I still do what I learned as a corneal fellow: observe the patient for clues before starting the slit lamp exam.

The patient may be blinking frequently to clear their vision, or perhaps they have skin manifestations of rosacea that would predispose them to blepharitis. They might have an incomplete blink, or lagophthalmos, or they may like to rub their eyes.

I ask about contact lens wear and level of comfort, and probe for symptoms of dry eyes or blepharitis. All of this is helpful in guiding my exam and helping in my ultimate IOL recommendation.

When I perform the slit lamp exam, I look at the lid margins for signs of anterior blepharitis or meibomian gland dysfunction. I assess the quality of the tear film and tear break-up time with fluorescein. I look for punctate staining, keratitis or other forms of irregular cornea, such as anterior basement membrane corneal dystrophy.

When it comes to treatment, I explain the nature of dry eye disease and why it needs to be treated. I start patients with newly diagnosed disease on artificial tears four times a day and consider punctal plugs at that first visit; I use collagen DuraPlugs (Katena) that dissolve after 3–4 months.

I have become much more inclined to add nutraceutical options such as HydroEye (ScienceBased Health) very early on in my treatment regimen. The patented formulation’s key ingredient is the unique anti-inflammatory fatty acid gamma linolenic acid (GLA), derived from blackcurrant seed oil.

 GLA is a precursor to the anti-inflammatory prostaglandin PGE1 and has been validated in a variety of clinical trials for improving dry eye symptoms in a range of patient populations.

The supplement includes a specific balance of other Omegas and nutrient co-factors to provide dry eye relief, and may change the chemistry of the meibomian glands as they start producing normal lipids, stabilising the tear film and relieving symptoms. Another benefit is patients’ acceptance. They are comfortable taking a natural option for the long term, and I make sure they understand that its anti-inflammatory effects can have systemic benefits as well.

I am leaning towards getting people to take nutraceuticals sooner rather than later because there are so many benefits, including not needing to take as many as with other topical medications. I discuss environmental changes with patients such as eliminating overhead fans and not allowing air vents to blow directly in their face. 

I also remind them that prolonged reading and binge-watching television or videos will exacerbate dry eyes.

If there is lid margin disease, I recommend hypochlorous acid-containing lid scrubs such as Avenova or OCuSoft, as well as a reusable warm compress such as a Bruder mask. I impress upon patients that we cannot take the preoperative measurements for cataract surgery until we see some significant improvement in their ocular surface and visual symptoms.

If necessary, I can add low-dose oral doxycycline, especially if there is meibomian gland disease. It has anti-inflammatory effects and it can change the function of the meibomian glands for the better.

Our practice has had success with heat and pulsation-type devices such as LipiFlow (Johnson & Johnson Vision) or the TearCare System (Sight Sciences). Often, we are able to break the cycle of lid margin and dry eye disease.

In patients who do not have lid margin disease, I will try a topical drop such as ciclosporin 0.05% (Restasis, Allergan), lifitegrast 5% (Xiidra, Novartis Pharmaceuticals), ciclosporin 0.09% (Cequa, Sun Pharmaceutical Industries) or corticosteroids (loteprednol 0.5% or fluorometholone 0.1%). Although these are not a cure-all, around half of my patients will respond.

I am honest and forthright when explaining to patients that the ultimate outcome of their cataract surgery depends on how they care for themselves. I point out that if they want to have reliable vision and be less dependent on glasses, they need to invest in their eyes and take the time and effort to prepare for surgery.

I remind patients that this is a lifetime commitment because there is no cure for dry eye disease. This means they cannot totally abandon caring for their ocular surface.

Dr Rosenfeld is in practice with Delray Eye Associates, PA, in Delray Beach, Florida, United States, and is a voluntary professor at Bascom Palmer Eye Institute in Miami, Florida. Dr Rosenfeld disclosed no relevant financial relationships.

Kapoor R, Huang YS. Gamma linolenic acid: an anti-inflammatory omega-6 fatty acid. 

Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. 

Macrì A, Giuffrida S, Amico V, et al. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. 

Aragona P, Bucolo C, Spinella R, et al. Systemic omega-6 essential fatty acid treatment and PGE1 tear content in Sjögren’s syndrome patients. 

Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. 

Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. 

Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. 

Sheppard JD, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. 

Patients need to pay attention to their eye health over the long term.

Optimising the ocular surface to achieve good vision after surgery

I started my surgical career as an anterior segment surgeon using a head loupe with a magnifica­tion of ×4 and without the possibility of IOL implanta­tion. A 180° opening of the eye with a knife, suturing it after expression of the cataract, was the rule.

Impressive improvements have been made but there are still obstacles to overcome.

The discovery of a short-acting (15–30 minutes) mydriatic would enable the patient to function nearly normally immediately after the procedure, and cataract surgery being performed in the upright position would also be beneficial to some patients. Most importantly, immediate sequential bilateral cataract surgery has many potential advantages such as fewer hospital visits for the patient, faster visual recovery and lower health care costs.

IOL/capsular bag dislocation decades after cataract surgery is an increasing problem. An estimated 1% of all cases will need to be revisited.

In the meantime, there are numerous variants of sulcus fixation. However, these are time-consuming, technically challenging and not without a certain poten­tial for complications.

I am working intensively on a simple, safe and effec­tive solution to the problem. I cannot reveal more yet, but the first clinical applications will start soon. That is my personal biggest challenge for the coming year and I hope to be able to report on it by the end of 2023.

The biggest challenge for our refractive surgery department in 2023 will be the incorporation of SMILE—or, better, call it laser lenticular extraction.

With the market introduction of new technical­ly competitive laser systems, the time seems to be ripe for this. Whether femto-LASIK will lose its gold standard status remains to be seen. It is the results that count, not the specifications from marketing depart­ments. However, it is quite possible that patients will decide which procedure will prevail in the end. Either way, laser lenticular extraction is an incredible enrich­ment to laser vision correction.

Endothelial keratoplasty such as Descemet membrane endothelial keratoplasty (DMEK) is the standard treatment for Fuchs endothelial corneal dystrophy and chronic corneal oedema.

However, surgical treatment without endothelial ker­atoplasty may serve as an alternative and could reduce the need for corneal transplantations. Recently, promis­ing results were presented for the injection of endothelial cells into the anterior chamber or Descemet stripping only, with or without Rho-kinase inhibitors, as well as for the implantation of an artificial endothelial layer.

Upcoming randomised controlled trials are necessary to evaluate and compare the results with those for cur­rent treatments such as DMEK.

Wearing a face mask has become routine. We are currently experiencing an increased prevalence of patients suffering from dry eye syndrome. Some of the symptoms can be directly connected to wearing face masks, thereby affecting all age groups, with an increased emergence being reported among the paediatric population.

While wearing a face mask, the exhaled air flows upwards, especially when the mask sits loosely around the nose and cheeks. Until now we have had no scientific proof for the cause of those symptoms. This needs to be evaluated because we have to educate our patients on how to avoid such symptoms.

The field of inherited retinal diseases has, over the past decade, seen an explosion in different therapeutic strategies being investigated to slow disease progression or even potentially restore visual function in end-stage disease.

One approach aims to use gene therapy to restore light sensitivity to remaining inner retinal cells once rods and cones have degenerated, with the aim of restoring vision in advanced disease. This method, known as optogenetics, has shown great advances in recent years, with four clinical trials now underway evaluating different gene therapy approaches, some in combination with visual prosthetic devices that augment the light stimulus to optimise responses. The patients who would benefit from these therapies are those with advanced visual loss (acuity of hand move­ments only or perception of light) but with preservation of inner retinal structures on optical coherence tomog­raphy scans.

Preliminary data from three of the ongoing trials have been released, with no serious adverse effects reported; two out of three trials report some improve­ment in visual function. Further data from these trials are keenly awaited, to determine whether optogenetic strategies may be able to restore visual function in blind patients.

For around 15 years I have been supporting the non-governmental organisation Light for the World,

 which is a global development organisation empower­ing people with disabilities and enabling eye health ser­vices in low-income countries. The organisation builds eye hospitals in Africa and delivers, in a very efficient way, eye care in less-developed countries.

We know that glaucoma is the most frequent cause of incurable blindness and must be stopped at all costs. Therefore—specifically for these undeveloped countries, mostly in hot climates—better and longer acting glaucoma eye medication has to be developed.

Using drops twice a day for a lifetime or accessing glau­coma surgery is not straight­forward in these countries. More efficient single doses, long-acting medication and the propagation of cheaper and easier to use glaucoma drainage implants may pre­vent further optic nerve dam­age and keep these people far away from blindness.

The longer lifespan of mankind is accom­panied by age-related diseases such as cataract and age-related macular degeneration (AMD). Unfortunately, for around 20 years, treatment has been available only for the less-common form, wet AMD.

For the most common form of macular degeneration, dry AMD, which represents about 80% of diagnosed cases, there is no efficient treatment yet.

Estimations are that, in the USA alone, 11 million peo­ple have dry AMD, while 1.5 million (~15% of all AMD) are affected by the advanced stages of the disease.

It would be a major challenge to find a way to pre­vent or eventually cure this disease. Millions of people would benefit from such a realisation.

Wet and dry AMD (wAMD, dAMD) is still a major sight-threatening disease. Healing of the disease is still not possible.

Anti-VEGF drugs seem to be a breakthrough. Howev­er, a portion of our patients do not respond adequately and their retinal pigment epithelium is altered as a result of the continous treatment.

In the next year we are expecting the first medi­cal treatments for dAMD and several biosimilars for wAMD. We will have to use our complete armamen­tarium (artificial intelligence in combination with multimodal imaging) to critically evaluate these new approaches/drugs.

A welcome challenge for retinal spe­cialists in 2023 is the advent of new, and in some cases longer acting, anti-VEGF agents for the treatment of retinal disease.

We have seen through 2022 the licensing and ap­proval of faricimab (Roche), an intravitreal agent that inhibits both anti-VEGF and Ang-2, with clinical trial data reporting a maintenance dosing interval of 16 weeks in approximately 45% of patients with AMD at week 48 after starting treatment.

We now therefore have four licensed anti-VEGF medications (ranibizumab [Novartis], aflibercept [Regeneron], brolucizumab [Novartis] and faricimab), with ranibizumab biosimilars also available, for both neovascular AMD and diabetic macular oedema.

It is now in the hands of retinal specialists to weigh up the relative benefits and cost-effectiveness of these different medications for their patient populations and to implement optimal protocols.

Further real-world data emerging through 2023 will aid and clarify these decisions, and clinical trials are also ongoing for gene therapy approaches to treat neo­vascular AMD, which may lead to even longer acting therapies in the coming years.

We are entering a new era of thinking. Senescence is no longer something we are willing to accept as a part of our life. We have enough scientific proof to look at senescence as a disease entity which can be—at least partly—antagonised. Several biotech companies are investigating drugs to help us achieve this goal. Ophthalmology is ideally suited to participate in this new development because we are facing a dra­matically increasing number of patients suffering from age-related diseases such as AMD, diabetes, glaucoma and cataract. Thus, we have to carefully observe the de­velopments and ideally participate as early as we can.

Because cataract is age-related, the need for surgery will go up with the rising average life expectancy of people on this planet. Although the cat­aract surgical rate is increasing in some countries—for example, in India the number of operations per million people per year increased from just over 700 in 1981 to 6000 in 2012

—there are still significant waiting lists in many countries. The surgery has to be made more affordable and eventually paramedics will have to be included in performing cataract surgery.

Patient Management and Demand for Services

We will need to improve perioperative management. Our productivity is insufficient. It starts with the acceptance of patients when we do not have sufficiently efficient telephone and appointment acceptance.

Patient counselling needs to start more effectively before patients come into the clinic. For now, we are just sending information leaflets to the patients. Tele-con­sulting would outsource precious chair time and help us to better pre-select the patients regarding their IOL preferences.

We currently lose too much time during the exam­ination in the clinic. Two to three hours is too much; we want to get to a maximum of 90 minutes. We will review everything that hinders the processes and increasingly focus on multifunctional aperitive diagnostics.

Here, too, artificial intelligence will play an important role. Maybe not in the coming year, but it will not be long before we will be able to compensate for the bottle­necks on the personnel side by significantly increasing productivity.

A major challenge we face as retinal spe­cialists is rapidly increasing demand. In the UK, the Roy­al College of Ophthalmologists predicts a 59% increase in cases of neovascular AMD between 2015 and 2035,

 and facilitating already stretched services to meet this challenge will require innovation and novel approaches.

Potential solutions include home monitoring of pa­tients with AMD, with the aim of detecting neovascular changes at an early stage. Several devices have shown positive results in clinical trials and are approaching utilisation in clinical practice, which may help to reduce the frequency with which patients need to be monitored in a hospital or clinic setting, as well as being more con­venient for this elderly group of patients.

Diabetic macular oedema and AMD con­tinue to increase. One of the major challenges in 2023 will be coping with the large number of patients in diag­nosis and therapy. We very much hope that the support of diagnostics by means of artificial intelligence and the approval of long-acting drugs will support us in this.

A further and ongoing challenge remains in delivering high-quality care across different patient populations who may have a range of barriers prevent­ing engagement with health care.

A prime example is that of diabetic screening: the UK is fortunate to have a national, population-based screening programme to detect diabetic eye disease, and if patients are detected to have significant or po­tentially sight-threatening changes of pre-proliferative or proliferative retinopathy, or maculopathy, they are referred to hospital eye services for further evaluation and treatment.

 in 2018/19, 2.8 million people with diabetes in the UK were invited to diabetic eye screening, 82.6% of whom attended their appoint­ments, with 74% to 92% uptake across different regions of the UK.

Given that 48% of people with type 1 diabetes and 28% of people with type 2 diabetes may develop retinal changes, it is essential to keep engaging with our patients with diabetes to improve screening uptake to enable early detection of potentially sight-threatening changes.

It is known that multiple factors influence screening uptake including social deprivation, being of an ethnic minority background, poorer blood sugar control, smoking and a lack of awareness of the risk of visual loss. We must therefore endeavour to overcome these barriers in conjunction with our physician colleagues by continuing to provide better education regarding the importance of screening.

Other documented barriers have been reported as accessibility, time (such as competing demands), sched­uling and doctor–patient communication, and although it is challenging to address these factors, with limited resources in many areas, the benefits of doing so are clearly evident.

Robot-assisted surgery has made its entrance in ophthalmic surgeries but, compared with other disciplines in medicine, we ophthalmologists— with some exceptions—are lagging behind in its use.

With robotic instrumentation, a precision of 1 mm may be provided and tremor can be avoided. The inte­gration of robotics in complicated surgical procedures has a long way to go, and the limited availability and high cost are challenges to be overcome. Higher effi­ciency and faster surgery in complicated cases could be the outcome.

The use of existing robots (such as the da Vinci sys­tem telemanipulator used for anterior and posterior interventions) has to become more widespread once some existing limitations have been addressed.

Artificial intelligence (AI) is rapidly finding its way into the health care systems around the world. The greatest challenge is to make AI as practical as possible. Different systems need to be combined to achieve a performance that is clinically acceptable.

Thus, the most significant technical challenge arises from the need for adequate training data and external validation. A further challenge is what happens in the case of misclassification or practical mistakes in gen­eral in terms of liability, i.e. whether the AI provider or the clinician is responsible.

In addition, many of these challenges are associated with the usual differences in access to health care.

After 30 years of clinical practice, I will slowly but surely prepare for retirement. Ophthalmology will then increasingly be more research and development for me.

But I will also have more time to take care of my personal well-being and that of my family, and I will have more time for writing. I am especially looking forward to that.

Joachim N, Mitchell P, Burlutsky G, et al. The incidence and progression of age-related macular degeneration over 15 years: the Blue Mountains eye study. 

Chou R, Dana T, Bougatsos C, et al. Screening for impaired visual acuity in older adults: updated evidence report and systematic review for the US preventive services task force. 

Heier JS, Khanani AM, Ruiz CQ, et al. Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials. 

Murthy GVS, Jain B, Shamanna B, Subramanyam D. Improving cataract services in the Indian context.

The Royal College of Ophthalmologists. The Way Forward: Age-Related Macular Degeneration and Diabetic Retinopathy. 

Public Health England. Atlas of variation in risk factors and healthcare for vision in England. 

Pichler PP, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. 

Members of the Ophthalmology Times Europe® Editorial Advisory Board were asked to predict developments in their ophthalmic specialties and interests for 2023. A focus is our ageing population, while efficiency and productivity are also on their minds. The board members agree that one of the major challenges in the year to come will be the large number of patients awaiting diagnosis and treatment, which is only going to increase with the rising average life expectancy worldwide.

2023: What ophthalmologists in Europe anticipate for the year ahead

A study of patient characteristics impacting on the continuity of paediatric ophthalmic care during the COVID-19 pandemic found that the beginning of the 2020 lockdown had four times the odds of incomplete visits compared with the previous year. 

According to Jenay Yuen and members of the multicentre research team led by Dr Alejandra de Alba Campomanes at the University of California San Francisco, California, United States, both visit follow-throughs and telemedicine utilisation were found to be impacted by health disparities.

Following the start of the pandemic, the role of telemedicine increased rapidly in clinical practices. Despite this development, the investigators explained, previous studies have shown the technology to be under-utilised by older patients, Black and Latinx patients, and those of lower socio-economic status.

Because information on telemedicine disparities in the paediatric ophthalmology population is lacking, Ms Yuen and colleagues conducted a retrospective, cross-sectional study of scheduled paediatric ophthalmology encounters before and during the initial COVID-19 pandemic. The study aimed to determine the effect of the pandemic shutdown on the odds of paediatric ophthalmology visit completion, along with factors associated with receiving visits via telemedicine.

More than 11,000 paediatric patients were included in this multicentre study. The participating institutions were the University of California San Francisco, Children’s Hospital Los Angeles, and the Oregon Health and Science University in Portland, Oregon, US. All patients had appointments scheduled before the pandemic (March 2019 to June 2019) or after the onset of the pandemic (March 2020 to June 2020).

The investigators reported that the completion rate of scheduled visits decreased from 72.4% in 2019 to 32.6% in 2020. Notably, only 8.8% of scheduled visits in March 2020 were completed, including both in-person and telemedicine modalities, which was a drastic decrease from 71.3% in March 2019.

During the first 4 months of the pandemic, 51% of completed visits were conducted remotely via telemedicine.

“The odds of not completing a visit in March to June 2020 were 4.77 times higher than that of 2019, after adjusting for sociodemographic and neighbourhood variables,” Ms Yuen said.

Race and ethnicity, age and preferred language were found to be relevant factors in this analysis. Specifically, Black patients had 1.35 times the odds of having an incomplete visit compared with non-Hispanic White patients in either year, after adjusting for other demographic and neighbourhood characteristics.

In both years, older children had increased odds of having an incomplete visit compared with patients younger than 1 year (odds ratio [OR] 1.44-1.85; all 

< 0.001). Patients who were non-English-speaking and needed an interpreter had lower rates of completed visits in 2020.

The primary factors impacting telemedicine use were follow-up appointments, presence of extraocular disease (compared with intraocular pathology) and race. In 2020, patients scheduled for follow-up appointments had 4.77 times the odds of having a remote visit compared with new patients. Patients with non-extraocular diagnoses had lower odds of engaging in a remote visit compared with patients who had a primary diagnosis of an extraocular disease (OR 0.12-0.51; 

Univariate analysis showed that all racial-ethnic groups had lower odds of engaging in a remote visit compared with non-Hispanic White patients. However, multivariate analysis did not show a significant difference.

The investigators enumerated these important findings: namely, that the initial period of the COVID-19 pandemic in 2020 was independently associated with the odds of an incomplete visit four times higher than that of the previous year, and that Black patients, older children and patients who were non-English-speaking were more likely to have incomplete visits.

“It is clear that health disparities exist and impact the rates of completed paediatric ophthalmology visits,” the investigators concluded. “[Although] these effects also impact the likelihood of having a remote visit, additional variables such as visit type and ocular disease seem to play an even larger role. Therefore, it is important to consider these additional clinical variables when considering the effectiveness of telemedicine in mitigating health disparities and increasing access to care.”

Ms Yuen is a medical student at the University of Southern California (USC) Roski Eye Institute, Keck School of Medicine of USC, California, US.

A study of paediatric ophthalmology visits during the COVID-19 pandemic reveals a sharp drop in completed visits, especially among Black patients, older children and non-English-speaking patients.

Health disparities: How the pandemic had an impact on paediatric ophthalmic visits

For two reasons, I often elect to perform goniotomy, also known as ab-interno trabeculectomy or goniectomy, on younger patients (under the age of 65) with mild, controlled glaucoma. Firstly, for better or worse, I often have patients who pride themselves in having researched premium cataract surgery options and glaucoma surgeries in preparation for their initial consultation with me.

At least once or twice a week, such a patient will call me to say that while they chose, for instance, a femtosecond laser-assisted cataract surgery with a toric IOL, they refuse the microstent that I am offering, because they are reluctant to add “more hardware” to their eye. The patient would rather continue on the two glaucoma medications they have been using.

Although I personally believe this is an unfounded concern, I cannot refer these patients to any peer-reviewed research on the risk of trabecular stents after 20 years. Also, I want to keep the nasal trabecular meshwork (TM) relatively spared to be available if future surgery should be required.

Secondly, because I accept nearly all insurances including Medicaid, certain payers will not provide prior authorisation for combined cataract surgery with trabecular stents, but they do authorise goniotomy. In either case, we miss a crucial opportunity for the patient to benefit from minimally invasive glaucoma surgery (MIGS) during their cataract surgery.

Fortunately, in both scenarios, I can perform a goniotomy at the time of cataract surgery. The “anti-hardware” patient is comforted that the procedure is safe enough to be performed on infants. The under-insured patient—who almost always gets coverage for goniotomy—will not get a surprise bill for an unpaid stent. In both cases, the goniotomy does not negate the possibility of future standalone glaucoma procedures.

I have been performing goniotomies since 2018, but I have had trouble with something that most surgeons would say is the biggest issue in this kind of procedure: hyphaemas. I am very concerned about prolonged hyphaema, having had several patients in whom I had to wash out the anterior chamber within a week in order to prevent worsening glaucomatous nerve damage.

Patients who experience prolonged postoperative hyphaemas are miserable. They have undergone this surgery in order to stop using eye drops, but the result is that they must return to the drops with worse issues than before. One-third of my patients undergo premium cataract surgery with a femtosecond laser or premium IOL or both, and they expect great results and are not prepared to tolerate hyphaema clouding their vision for 2 weeks after surgery.

I was first attracted to the devices TrabEx and TrabEx+ (MicroSurgical Technology) because of their potential to manage reflux bleeding. There are multiple elements of the design of these products that make this a possibility.

Focusing on the TrabEx+, it has an irrigation/aspiration system and its ability to provide irrigation enables the anterior chamber to remain pressurised. As I cut into the TM, the device aspirates and pulls it up, removing the need to push down on the tissue. Any blood along the way is vacuumed up, providing crystal clear vision with zero blood reflux while the procedure is underway.

The smooth footplate allows me to pass the sharp tip of the device through Schlemm’s canal, pulling the TM towards me so that it is not necessary to posteriorly push down deeper into the canal. It is a clean-cut excision of the TM with no reflux and no lacerated tissue of the TM left over (

Visibility is fantastic, both because the chamber is maintained and because blood reflux is aspirated along the way. This makes the goniotomy procedure easier, less stressful and even quicker in my experience.

In any goniotomy, you may see a little hyphaema. I tell my patients that I want to see a little blood because it means I have achieved passage through the collector channels. This small hyphaema is managed easily.

In addition to using the aforementioned device, I have three tips for avoiding hyphaema:

1. Put the patient in reversed Trendelenburg position with the entire table tilted at a 20–30° angle, which helps reduce the episcleral venous pressure within Schlemm’s canal.

2. Keep the eye slightly pressurised, with an mmHg in the 20s at the end of surgery. I have been surprised that what I used to think was “too firm” a pressure was actually only in the teens. To become more accurate at learning my tactile pressure with a more objective measure, early on, I started using the Terry-Kratz modified Barraquer tonometer (Ocular Instruments), which we traditionally use during Alcon Optiwave Refractive Analysis.

3. Tell patients to sleep upright, at a 30–40° angle, the first night. Because I have had various patients suffer from postoperative hyphaemas after sleeping upright but with their head tilted down, I give them the rule, “Keep your eye level above your chin, and your head level above your heart.”

Another technique that can help is patching the eye, which puts more pressure on it and can work as a reminder to patients that they have had surgery, need to be careful and should follow my instructions.

I recommend that one is gentle when performing the goniotomy. We surgeons can be quite used to pushing and hugging the canal as we cut along the TM. With the TrabEx+, it is not necessary, as the tip is so sharp the aspirating function pulls the tissue up as you move along.

It is not a case of “scooping up” the meshwork; it just “floats” into the tip. If any resistance or turning of the device is felt, then the surgeon may have gone too far posteriorly and is hitting the outer wall of Schlemm’s canal (

Regarding patient selection criteria, I do not do any kind of goniotomy on patients on blood thinners. Aspirin at a dosage of 81 mg is fine, but if the patient is on a prescribed anticoagulant, I do not perform the procedure.

MIGS is evolving rapidly, and when considering what is best for patients in terms of safety profiles and efficacy, it is not sufficient to continue using the same traditional stents and tube shunts procedures for lowering IOP. The beauty of the TrabEx+ is that it is a decades-old concept that uses cutting-edge technology. It blends the best of a proven safety record and a novel way of performing goniotomy.

If one has struggled with hyphaemas before, then this is the device to try. With its good technique, visibility and great outcomes, it has one of the easiest learning curves of any of the MIGS devices. Let this be your introduction into the extended world of MIGS.

Dr Desai is a glaucoma specialist at the Witlin Center for Advanced Eye Care, New Jersey, United States. He is a consultant for Ocular Therapeutix, Bausch & Lomb, Iridex, Sight Sciences, Ivantis, Alcon, MicroSurgical Technology, AbbVie and New World Medical.

A new device for goniotomy has the advantage of an irrigation/aspiration system, which offers easier excision of the trabecular meshwork and better visibility. Dr Desai shares his experiences using the device as well as his tips
and surgical pearls for success.

 New goniotomy device + careful post-op care limits intraoperative bleeding

This article was reviewed by Marissa Patel.

Intravitreal injections of unapproved stem cell therapies have resulted in irreversible blindness. Lack of patient understanding of stem cell treatments, and the actions of predatory practitioners, have led to these devastating consequences. There are currently no stem cell therapies approved by the United States Food and Drug Administration (FDA) to treat retinal diseases, and the clinical trials evaluating their efficacy and safety are only now under way.

Marissa Patel, an MD candidate at the University of Miami Miller School of Medicine, and Dr Jayanth Sridhar, of the Bascom Palmer Eye Institute, Florida, US, along with their colleagues conducted a survey of patients at a retina clinic to determine their level of understanding of stem cell treatments. The 87 participants who received the survey were adults who presented to the retina clinic because they needed intravitreal injections.

The study ran from 28 February 2020 to 18 March 2021. The main outcome was the percentage of patients who would be willing to undergo an unapproved stem cell therapy. The results of the survey were concerning and reflected the lack of knowledge about the status of stem cell therapies. 

Four views uncovered by the survey were as follows (see 

■ 76.7% of respondents said they believed that there are currently stem cell therapies for retinal disease being investigated in FDA-approved trials;

■ 40.7% of respondents said they would consider stem cell therapies that are not approved by the FDA;

■ 65.5% of respondents said they believed that all clinical trials found online were regulated by the FDA; and

■ Only 10.5% of respondents said they knew about the risks associated with non-FDA-approved stem cell therapy used to treat retinal disease.

In addition, 89.7% of respondents had not spoken to a medical professional about the risks and/or the benefits of stem cell therapies for treating retinal disease. Consideration of the responses by ethnic group showed that 66% of Hispanic patients said they believed that all clinical trials found online were regulated by the FDA, in contrast to 34% of non-Hispanic patients, who did not have that belief. This difference reached statistical significance (

Consideration by sex indicated that 100% of men were aware of the risks associated with unapproved stem cell treatments for retinal disease and no women reported such awareness. This difference was significant (

The primary finding of this survey is the depth of the confusion among patients being treated with intravitreal injections, regarding the federal regulations of the use of stem cell therapies to treat retinal disease.

Ms Patel explained that proper dissemination of information is important because of the extreme risks (i.e., retinal detachment and irreversible blindness) associated with unproven stem cell therapies. She stated that stem cell clinics advertise online, and many advertise their research on the US National Library of Medicine’s ClinicalTrials.gov site (

) without mentioning their investigational new drug status with the FDA.

According to Ms Patel, information about stem cell clinics should be publicly displayed on commonly encountered patient education sites, such as retinal society websites with patient education aims. Patients should be advised about the status of FDA-approved trials of stem cell therapies, and, more specifically, that no stem cell therapies are currently available. Finally, women and Hispanic patients seem to be more vulnerable to the disseminated misinformation about unapproved stem cell therapies.

Marissa Patel is an MD candidate at the University of Miami Miller School of Medicine in Florida, US. She has no financial disclosures.

A recent survey of retinal clinic patients reveals a lack of awareness of the risks and safety issues associated with stem cell therapies.

What patients do and don't know about stem cell therapy

The treatment of presbyopia has historically relied on reading glasses or bifocal/varifocal lenses, which can be poorly tolerated, particularly by patients who do not routinely wear glasses. 

Today, several surgical options offer patients the chance of having spectacle-free near vision without compromising on intermediate and distance vision. In patients who do not have cataract, one of the safest and most versatile options for achieving this is the use of presbyopia-correcting laser refractive surgery.

Corneal refractive surgery or lens exchange?

Laser refractive surgery avoids the potential complications of refractive lens-exchange procedures, which include the loss of contrast sensitivity and stereopsis as well the risks of intra­ocular surgery.

 Corneal laser ablation is a less invasive procedure that en­ables a greater degree of customisation to accommodate the lifestyle needs of patients. 

Additionally, some corne­al-based procedures, such as corneal inlay surgery, have the advantage of being reversible.

Corneal laser ablation retreatment allows for the management of refractive surprise and postoperative refractive changes, ultimately leading to im­proved patient satisfaction and visual outcomes.

 Recent advancements in presbyopia refractive laser surgery techniques have further improved outcomes. One of these techniques is Presbyond laser blended vision (LBV).

Presbyond LBV is a femtosec­ond-LASIK procedure for treating presbyopia, which involves modifying the corneal surface. The technique combines the principles of monovision and extended depth of field to create a blend zone that enables a smooth transition from distance to intermediate to near vision between the two eyes.

A corneal refractive technique can combine monovision and extended depth of field to create a wide, seamless range of functional vision. This can provide independence from spectacles.