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COVID-19 has placed unprecedented pressure on health systems globally, whereas simultaneously stimulating unprecedented levels of transformation. Here, we review digital adoption that has taken place during the pandemic to drive improvements in ophthalmic clinical care, with a specific focus on out-of-hospital triage and services, clinical assessment, patient management, and use of electronic health records. We show that although there have been some successes, shortcomings in technology infrastructure prepandemic became only more apparent and consequential as COVID-19 progressed. Through our review, we emphasize the need for clinicians to better grasp and harness key technology trends such as telecommunications and artificial intelligence, so that they can effectively and safely shape clinical practice using these tools going forward.

*Correspondence - Luis García-Onrubia: luis.garciaonrubia@gstt.nhs.uk OBJECTIVE: To report the clinical outcomes of a series of cases in which localised areas of endothelial function were selectively treated with shape and position matched endothelial transplanted in a procedure we have termed Descemet's membrane endothelial patching (DMEP).Interventional case series. Five patients presented with localised endothelial dysfunction in eyes with high-risk graft failure due either to rejection, recurrence of the focal endothelial dysfunction or because extended treatment with steroid drops was contraindicated. Endothelial grafts matching the area of dysfunction were produced to preserve healthy host cells and limit the immunological burden of new grafts. Patient demographic details, indication for surgery, preoperative and postoperative visual acuity, intraoperative and postoperative complications, and graft rejections episodes were noted.Five patients were included in this cases series. Indications for DMEP were Fuchs' heterochromic iridocyclitis (n=1), Fuchs' endothelial dystrophy (n=2), endotheliitis (n=2). In all cases, a customised DMEP graft was used, as opposed to our standard 8.25mm circular DMEK graft size. The DMEP grafts were centred over the area of focal endothelial dysfunction. In all cases, complete graft attachment was achieved, and the corneas were cleared. Steroid drops were reduced rapidly without any episodes of graft rejection/failure reported at 1 year.DMEP transplants are a viable option to treat localised endothelial dysfunction. Placing non-circular, no central transplants is surgically feasible and does not appear to affect graft adhesion. Limiting the size of the transplant may limit the immunological burden of new grafts and reduce the need for extended courses of steroids.

We read with interest your article describing a new objective method for evaluating glistenings in intraocular lenses (IOLs) in vivo [...]

Purpose There is a need for a simple and accurate way to assess visual acuity in telemedicine consultations in ophthalmology and other related specialties. Design We surveyed visual acuity testing apps available that allow patients to measure their own acuity, focusing on freely accessible resources suitable for all resource settings. Methods A systematic search was performed for visual acuity testing apps on 2 major platforms: Google Play Store (Google, CA, USA) and Apple App Store (Apple, CA, USA). Results Sixteen apps (67%) tested near vision, 5 apps (21%) tested distance vision, and 3 apps (13%) offered options for both near and distance vision testing. Of the 24 apps, 5 (21%) offered a method of calibration of optotype size. Three apps (13%) demonstrated evidence of clinical validation. Only 3 apps fulfilled our criteria for suitability for clinical practice. Conclusions We have recommended 3 apps that may be quickly integrated into clinical practice in both ophthalmic and non-ophthalmic all resource settings.

*Correspondence - Luis García-Onrubia: luis.garciaonrubia@gstt.nhs.uk PURPOSE: To describe a novel technique for deep anterior lamellar keratoplasty (DALK) in patients central corneal perforation and deep scarring making conventional DALK (Melles or Big Bubble) unviable. A posterior Descemet's membrane (DM) skirt has provided an adequate scaffold for the migration of the host endothelial cells.A case report. A 32-year-old male with previous hydrops developed severe corneal scarring with a break in DM visible on OCT scanning. A modified DALK procedure was perform consisting of a 400µm, 8.5mm Anterior lamellar cap with a 4.5mm posterior lamellar disc, denuded of endothelial cells and containing a DM skirt.Initially, manual dissection of the and anterior 400µm of corneal stroma was performed using a modified Melles technique. The residual posterior lamellar was assessed and found to have significant residual scarring. A central 4mm optical window was performed through the posterior lamellar over the visual axis.The donor tissue was cut using a 350µm microkeratome head. The anterior cap was trephined to 8.5mm and set aside. The posterior lamellar was placed in a punch block, and the endothelial was removed using a silicone tipped cannula. The removal of endothelial cells was confirmed using trypan blue dye. A posterior lamellar graft with a 4.0mm stromal bed and a 4.5mm DM skirt was fashion using a peeling and double punch technique. The posterior lamellar graft was inserted into the optical window such that the DM skirt provided a bridge to the donor corneal endothelium. The anterior cap was sutured with a double continuous suture of 10-0 monofilament nylon. An inferior peripheral iridotomy was created, and an air bubble filling the anterior chamber was left at the end of the case.The preoperative visual acuity (VA) was hand movements. Full attachment of the posterior lamellar was seen at all time-points from week one onwards. Central corneal pachymetry continued to reduce for 12 weeks. One year after the operation, with sutures in, the best spectacle-corrected VA was 6/12. The corneal graft was clear, and no rejection episodes occurred. Endothelial cell repopulation of the donor DM could be observed with specular microscopy.The presence of DM promotes endothelial migration and healing. Modifications to traditional DALK surgery, in which DM is used to promote endothelial healing, are a viable alternative to penetrating keratoplasty. This method eliminates the risk of allograft endothelial rejection and allows a 'regenerative' for DALK to be used, offering a new modality of treatment in patients with healthy reserves of endothelial cells and deep posterior lamellar scarring.

Learning Objectives Upon completion of this activity, participants will be able to:Assess the efficacy of off-the-shelf use of 2-diopter cylinder correction toric intraocular lenses in cataract surgery for patients with preoperative corneal astigmatism of 2.00 D or more, based on a prospective randomised study.Evaluate the safety and patient-reported outcomes of off-the-shelf use of 2-diopter cylinder correction toric intraocular lenses in cataract surgery for patients with preoperative corneal astigmatism of 2.00 D or more, based on a prospective randomised study.Determine the potential suitability of off-the-shelf use of toric intraocular lenses for more widespread adoption by the National Health Service or other large public health programs, and other clinical implications of their efficacy and safety, based on a prospective randomised study. Continuing Medical Education In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Springer Nature. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at www.medscape.org/journal/eye; (4) view/print certificate. Credit hours 1.0 Release date: July 30, 2020 Expiration date: July 30, 2021 Post-test link: https://medscape.org/eye/posttest929021 Authors/Editors disclosure information Sobha Sivaprasad, MD, has disclosed the following relevant financial relationships: served as an advisor or consultant for: Allergan, Inc.; Apellis; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Heidelberg Pharma GmbH; Novartis; Oculis; Optos; Oxurion; Roche. Served as a speaker or a member of a speakers bureau for: Allergan, Inc.; Bayer AG; Novartis Pharmaceuticals Corporation; Optos. Received grants for clinical research from: Allergan, Inc.; Bayer AG; Boehringer Ingelheim Pharmaceuticals, Inc.; Novartis Pharmaceuticals Corporation; Optos. Nick Stanojcic, BSc, MCOptom, FRCOphth, has disclosed no relevant financial relationships. Harry Roberts, MSc, FRCOphth, has disclosed the following relevant financial relationships: served as an advisor or consultant for: Alcon UK. Vijay Wagh, FRCOphth, has disclosed no relevant financial relationships. Bruno Zuberbuhler, PhD, FRCOphth, has disclosed no relevant financial relationships. David O'Brart, MD (Res), FRCOphth, FRCS, RefCert(RCOphth), has disclosed the following relevant financial relationships: received grants for clinical research from: Alcopn Inc., Rayner Ltd, Avedro Inc. Owns stock, stock options, or bonds from: Sparca Inc. Employed by a commercial interest: Sparca Inc., Background/objectives To compare visual and refractive outcomes of monofocal intraocular lenses (IOLs) with limbal relaxing incisions (LRI) with ‘off-the-shelf’ use of toric IOLs (TIOLs), with a fixed 2-dioptre cylinder (DC) correction, for cataract patients with pre-existing corneal astigmatism in a public-sector setting. Subjects/methods Seventy-seven patients (77 eyes, first treated eye) with visually significant cataract and pre-operative corneal astigmatism ≥2.00 DC were randomised to receive either ‘off-the-shelf’ TIOLs, with a fixed 2.00 DC cylinder correction (39 eyes), or monofocal IOLs (38 eyes) with LRIs. The concept of fixing the cylindrical correction was to minimise costs, allow a full TIOL bank to be available and eliminate the need for individual TIOL ordering. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and refraction. Astigmatic changes were evaluated using the Alpins vector method. Results Mean UDVA improved from logMAR 0.88 (SD 0.56)[~20/150] pre-operatively to 0.18 (SD 0.19)[~20/30] post-operatively in TIOL group, versus 0.82 (SD 0.55)[~20/130] to 0.27 (SD 0.15)[~20/40] in monofocal/LRI group (P = 0.02; 95% CI: −0.17, −0.01). Mean CDVA improved from logMAR 0.40 (SD 0.26)[~20/50] to 0.01 (SD 0.12)[~20/20] in TIOL group, and 0.41 (SD 0.38)[~20/40] to 0.06 (SD 0.12)[~20/25] in LRI group (P = 0.07; 95% CI: −0.11, 0.01). Average post-operative refractive cylinder in TIOL group was 1.35 DC (SD 0.84 DC) and in LRI group 1.91 DC (SD 1.07 DC) (P = 0.01; 95% CI: −1, −0.12). Mean difference vector magnitude was 1.92 DC (SD 1.08 DC) in LRI group and 1.37 DC (SD 0.84 DC) in TIOL group (P = 0.02; 95% CI: 0.11, 0.99). Conclusions TIOLs with a fixed 2.00 DC correction during cataract surgery may improve UDVA, reduce post-operative cylinder and result in a more reliable astigmatic correction compared with monofocal IOLs with LRIs.

The purpose of this study was to report a novel surgical technique for altering donor Descemet membrane endothelial keratoplasty (DMEK) curvature to match host posterior stroma in a patient with advanced keratoconus (KC) and endothelial decompensation.We report a 56-year-old man with Fuch endothelial dystrophy and KC, who underwent DMEK due to endothelial decompensation. A triangular area of graft detachment centered on the apex of cones persisted after repeat gas tamponade. A radial incision from the graft edge to the apex was used to allow overlapping of the graft, thereby increasing the grafts curvature.The use of a radial incision in the Descemet membrane (DM) graft was made to allow the graft overlap and adapt to the new shape. By matching the donor curvature to that of the hosts posterior curvature, full adhesion of the graft was achieved with the use of a short-acting air bubble by 1 week after the procedure.The mismatch in the curvature of the DM graft and the host posterior corneal surface, in cases with KC or very steep corneas, should be taken into consideration because it can lead to redundancy folds. These can result in atypical, conical detachments, distinct from the typical peripheral detachments seem commonly in DMEK. A single radial incision in the DM graft combined with air tamponade is a feasible treatment option in cases where DMEK fails to attach because of apparent curvature mismatch between the donor and host.

We describe two patients in whom postsurgical refractive error occurred after routine refractive lens exchange cataract surgery with multifocal intraocular lens insertion most likely attributable to the presence of underlying corneal epithelial basement membrane dystrophy (EBMD). In Case 1, there was an unexpected hyperopic postoperative spherical equivalent refractive error of +1.50 diopters and in Case 2, a cylindrical refractive error of 2.75 diopter cylinder. We examine the possible causes of error and discuss potential management strategies to prevent and address these unpredictable postoperative outcomes. The importance of comprehensive and careful ocular surface assessment before cataract or refractive surgery as part of the presurgical workup is reemphasized. EBMD can be subtle and if overlooked, can affect the validity of biometric keratometric measurements preoperatively, resulting in an inaccurate biometry measurement, incorrect IOL selection, and reduced visual performance and patient satisfaction.

To assess the performance of a deep learning (DL) algorithm for evaluating and supervising cataract extraction using phacoemulsification with intraocular lens (IOL) implantation based on cataract surgery (CS) videos.DeepSurgery was trained using 186 standard CS videos to recognize 12 CS steps and was validated in two datasets that contained 50 and 21 CS videos, respectively. A supervision test including 50 CS videos was used to assess the DeepSurgery guidance and alert function. In addition, a real-time test containing 54 CSs was used to compare the DeepSurgery grading performance to an expert panel and residents.DeepSurgery achieved stable performance for all 12 recognition steps, including the duration between two pairs of adjacent steps in internal validation with an ACC of 95.06% and external validations with ACCs of 88.77% and 88.34%. DeepSurgery also recognized the chronology of surgical steps and alerted surgeons to order of incorrect steps. Six main steps are automatically and simultaneously quantified during the evaluation process (centesimal system). In a real-time comparative test, the DeepSurgery step recognition performance was robust (ACC of 90.30%). In addition, DeepSurgery and an expert panel achieved comparable performance when assessing the surgical steps (kappa ranged from 0.58 to 0.77).DeepSurgery represents a potential approach to provide a real-time supervision and an objective surgical evaluation system for routine CS and to improve surgical outcomes.

Purpose To compare the Clareon IOL with the Tecnis PCB00 IOL in terms of visual performance, refractive outcomes, glistenings occurrence, and quality-of-life outcomes. Setting Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom. Design Single-center, single-masked, prospective, randomized controlled trial. Methods One hundred thirty-nine patients with bilateral cataracts were randomized to receive the Clareon (C IOL) or Tecnis (T IOL) IOL. Visual acuity, refraction, central corneal thickness (CCT), endothelial cell loss, contrast sensitivity, mesopic gap acuity, evaluation of glistenings, and rates of perioperative and postoperative complications were recorded. Quality-of-life outcomes were measured with the EuroQOL-5 dimensions questionnaire and the patient-reported outcome measures (PROMs) questionnaire. Optimized A-constants were available for the T IOL but not for the C IOL. Results Seventy-one patients (140 eyes) received the C IOLs and 68 patients (134 eyes) received the T IOLs. Data were analyzed for the first implanted eye. At 12 months, mean uncorrected distance visual acuity (logarithm of the minimum angle of resolution) was 0.02 ± 0.10 and 0.01 ± 0.08 (mean ± SD; P = .49; 95% CI, -0.02 to 0.04) in the C IOL and T IOL groups, respectively. Corrected distance visual acuity was -0.02 ± 0.09 and -0.03 ± 0.06, respectively (P = .45; 95% CI, -0.02 to 0.04). The increase in CCT was 14 ± 19 and 16 ± 28 μm, respectively (P = .63; 95% CI, -10.16 to 6.16). Mean absolute refraction spherical equivalent error from target refraction was 0.41 ± 0.28 for the C IOL and 0.25 ± 0.2 for the T IOL groups (P = .002; 95% CI, 0.08 to 0.24). Glistenings were minimal (median grade 0), with no difference in grades between groups (P = .2). PROMs improved postoperatively and were similar in both groups. Conclusions There were no differences in visual outcomes between the Clareon IOL and Tecnis PCB00 IOL. Glistenings were rarely observed in either IOL with no difference in grades. There was no difference in perioperative or postoperative complications. Surgeon optimization of the A-constant for the Clareon IOL is recommended.

Aims To report 12-month outcomes of randomised controlled trial comparing conventional phacoemulsification surgery (CPS) with femtosecond laser-assisted cataract surgery (FLACS). Methods This was a single-centre, prospective single-masked randomised case-controlled trial. Four hundred patients were randomised to CPS or FLACS with the LenSx platform (Alcon Laboratories Inc.). Visual acuity, refraction, central corneal thickness, endothelial cell loss (ECL), adverse events and quality of life outcomes, using EuroQOL 5-dimensions (EQ-5D-3 L) and cataract surgery patient-reported outcome measures (PROMs) questionnaires (Cat-PROM5), were recorded. Results Two hundred and thirty four patients (58.5%) attended 12-month follow-up (116 FLACS, 118 CPS). Mean LogMAR unaided distance visual acuity) (±SD) was 0.12 (0.18) with FLACS and 0.13 (0.19) with CPS (p=0.68; 95% Confidence Interval [CI]−0.06,0.04). Mean spherical equivalent (SE) refraction was −0.1±0.6 diopters (D) with FLACS and −0.2±0.6 D with CPS (p=0.44; 95% CI −0.09, 0.21). Mean corrected distance visual acuity (±SD) was −0.01 (0.1) with FLACS and 0(0.1) with CPS (p=0.45; 95% CI −0.04,0.02). Two patients per group underwent YAG laser capsulotomy for posterior capsular opacification (p=1). Mean ECL (per mm2±SD) was 301±320 with FLACS and 228±303 with CPS (p=0.07; 95% CI −7.26, 153.26). Mean Cat-PROM scores (±SD) were −5.5 (2.6) with FLACS and −5.8 (2.5) with CPS (p=0.3; 95% CI 0.31,1.01). EQ5-3DL mean index score (±SD) was 0.92 (0.13) with FLACS and 0.89 (0.14) with CPS (p=0.1; 95% CI −0.1, 0.01). Vector analysis comparing manual limbal relaxing incisions (LRIs) and intrastromal femtosecond laser-assisted astigmatic keratotomies (iFAKs) showed a greater correction index (p=0.02; 95% CI 0.06 to 0.60) and smaller difference vector (p=0.046; 95% CI −0.54, −0.01) with iFAK. Conclusions There were no differences in vision, refraction, adverse postoperative events or PROMs between FLACS and CPS groups at 12 months. iFAKs may provide more effective astigmatic correction compared to LRIs, 12 months postoperatively.

ObjectiveTo investigate the effect of intraocular lens (IOL) glistenings on visual performance and evaluate a new glistenings grading methodology.Methods and AnalysisThirty-four patients (34 eyes) were recruited. Corrected distance visual acuity (CDVA), mesopic gap acuity (MGA), functional contrast sensitivity (FCS) and forward light scatter were measured (Advanced Vision and Optometric Tests, City Occupational, London, UK). The IOL centre was imaged and glistenings density graded by three observers using the Miyata scale and a new system. Inter-rater reliability, association between the two grading scales, and correlations between glistenings grades and visual performance parameters were evaluated.ResultsThe intraclass correlation coefficient between graders for the new grading system was 0.769 (95% Confidence Interval [CI] 0.636 to 0.868). There was a significant association between the Miyata scale and the new grading system for all graders (rs=0.533–0.895, p≤0.001). There was no association between CDVA or MGA and glistenings grade (rs=− 0.098, p=0.583 and rs=0.171, p=0.359, respectively). There was no association between FCS at mesopic light levels and glistenings grade (rs=−0.032, p=0.864), or the straylight parameter and glistenings grade (rs=0.021, p=0.916). No association was found between the integrated straylight parameter and glistenings grade (rs=0.078, p=0.701).ConclusionThe new glistenings grading scale was highly reproducible. In this cohort, glistenings in the same hydrophobic acrylic IOL after cataract surgery were not associated with changes in visual function, as assessed by a series of tests not previously used in glistenings research.

Purpose: To review the published scientific literature concerning clinical and material degradations of intraocular lenses after implantation in cataract surgery. Methods: A search was undertaken using the following databases: CENTRAL (including Cochrane Eyes and Vision Trials Register; The Cochrane Library: Issue 2 of 12 February 2019), Ovid MEDLINE (R) without Revisions (1996 to February week 2, 2019), Ovid MEDLINE (R) (1946 to February week 2, 2019), Ovid MEDLINE (R) Daily Update 19 February 2019, MEDLINE and MEDLINE non-indexed items, Embase (1980–2019, week 7), Embase (1974–2019, 19 February), Ovid MEDLINE (R) and Epub Ahead of Print, in-Process & Other Non-Indexed Citations and Daily (1946 to 19 February 2019), Web of Science (all years), the metaRegister of Controlled Trials ( mRCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrial.gov ) and the WHO International Clinical Trials Registry Platform ( www.who.int/ictrp/search/en ). Only published articles in English were selected. Search terms/keywords included ‘IOL’ or ‘intraocular lens’, combined with ‘opacification’, degradation, glistenings, nanoglistenings, whitening, transmittance, light scatter, discolouration/discoloration, performance, quality, material, biocompatibility, calcification, explantation and ultraviolet/UV radiation. Relevant in-article references not returned in our searches were also considered. Results: After review of the available articles, the authors included 122 publications in this review, based on the quality of their methodology and their originality. The studies included in this review were randomized controlled trials, cohort studies, case-controlled studies, case series, case reports, laboratory studies and review papers. Differing material degradations of intraocular lenses have been described and their associated pathophysiology studied. Reported anomalies include photochemical alterations, water vacuoles, internal and surface calcific deposits, surface coatings and discolouration. The nature of such changes has been shown to depend on the type of intraocular lenses material used and/or manufacturing processes and storage conditions employed. Changes in the intraocular lens can also be influenced by surgical technique, coexisting ocular pathologies and topical and systemic medications. The clinical significance of these degradations is variable, with some resulting in significant visual disturbance and the need for intraocular lens explantation and others producing only minimal visual impairments. Failure to recognize the precise nature of the problem may lead to unnecessary laser capsulotomy procedures. Conclusion: Clinical degradations of intraocular lenses are uncommon but have been reported following the implantation of intraocular lenses made of differing biomaterials. Their correct identification and thorough investigation to determine the underlying cause is necessary for optimal patient management and the prevention of such problems. Choosing a lens made of a particular material may be important in patients with certain ocular conditions.

We report a case in which a Malyugin ring was left in the eye for 1 week after phacoemulsification complicated by an intraoperative suprachoroidal hemorrhage. The suprachoroidal hemorrhage resolved within a few days. One week postoperatively, an intraocular lens was implanted in the capsular bag and the Malyugin ring was removed uneventfully. One month after the secondary procedure, the uncorrected distance visual acuity was 0.1 logMAR (6.0/7.5 Snellen). The case shows that a Malyugin ring can be left in the eye safely for a week in cases of intraoperative suprachoroidal hemorrhage. It is an example of an unintended benefit of a pupil-dilating device. To our knowledge, this is the first report of this occurrence. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.