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Purpose To demonstrate different topographic distributions of multiple-evanescent white dot syndrome (MEWDS) and secondary MEWDS disease and to describe possible associations. Methods Clinical evaluation and multimodal retinal imaging in 27 subjects with MEWDS (29 discrete episodes of MEWDS). Ophthalmic assessment included best-corrected visual acuity testing and multimodal retinal imaging with OCT, blue-light autofluorescence, fluorescein and indocyanine green angiography, fundus photography, and widefield pseudocolor and autofluorescence fundus imaging. Results The topographic distribution of MEWDS lesions was centered on or around the optic disc (n = 17, 59%), centered on the macula (n = 7, 24%), sectoral (n = 2, 7%), or was indeterminate (n = 3, 10%). The MEWDS episodes either occurred in the absence (‘primary MEWDS’; n = 14, 48%) or presence of concurrent chorioretinal pathology (‘secondary MEWDS’; n = 15, 52%). In patients with the latter, MEWDS lesions were often centered around a coexisting chorioretinal lesion. The majority of patients in both groups experienced resolution of their symptoms and retinal changes on multimodal imaging by 3 months. Conclusions Distinct distributions of MEWDS lesions were identified. MEWDS may occur in tandem with other chorioretinal pathology, which may impact the topography of MEWDS lesions.

Purpose Existing research hints that people living with and beyond cancer are at an increased risk of stroke. However, there is insufficient evidence to appropriately inform guidelines for specific stroke prevention or management for cancer patients. We conducted a systematic review and meta-analysis to describe and quantify stroke incidence in people living with and beyond cancer. Methods Medline, CINAHL, and EMBASE were searched for epidemiological studies comparing stroke incidence between cancer and non-cancer patients. Reviewers independently extracted data; random-effects meta-analyses and quality assessment were performed. Results Thirty-six studies were narratively synthesised. Meta-analysis was conducted using seven studies. Methodological quality was high for most studies. Study populations were heterogeneous, and the length of follow-up and risk factors varied. There was a variation in risk between different cancer types and according to stroke type: pancreatic (HR 2.85 (95% CI 2.43–3.36), ischaemic) (HR 2.28 (95% CI 1.43–3.63), haemorrhagic); lung (HR 2.33 (95% CI 1.63–3.35), ischaemic) (HR 2.14 (95% CI 1.45–3.15), haemorrhagic); and head and neck (HR 1.54 (95% CI 1.40–1.69), haemorrhagic) cancers were associated with significantly increased incidence of stroke. Risk is highest within the first 6 months of diagnosis. Narrative synthesis indicated that several studies also showed significantly increased incidence of stroke in individuals with colorectal cancer, breast cancer, ovarian cancer, nasopharyngeal cancer, leukaemia, and myeloma, and those who have received radiotherapy for head and neck cancers and platinum-based chemotherapy may also have higher stroke incidence. Conclusions Stroke incidence is significantly increased after diagnosis of certain cancers. Implications for Cancer Survivors Cardiovascular risk should be assessed during cancer survivorship care, with attention to modifying shared cancer/cardiovascular risk factors.

Purpose To report a case of bilateral iatrogenic pigmentary glaucoma secondary to cosmetic iris-lightening laser treatment. Case report A 39-year-old patient presented with bilateral iatrogenic pigmentary glaucoma. She had elevated intraocular pressures (IOPs), scattered iris pitting, and intense angle pigmentation secondary to the cosmetic laser treatment she underwent 4 weeks prior to presentation. Her IOPs were refractory to maximal medical treatment and she subsequently underwent trabeculectomy. Conclusion The true scale of complications related to cosmetic laser treatments is as yet unknown. Robust clinical investigations into its safety profile, including long-term data, are required. Prospective patients should consider this with great care. Clinicians should be aware of the potential risks of this procedure, as early recognition of cosmetic laser-induced pigmentary glaucoma may avert further sequelae.

To report a case of multiple evanescent white dot syndrome (MEWDS) associated with acute progression of lacquer cracks in high myopia.A 41-year-old female patient with high myopia developed typical signs, symptoms, and disease course of MEWDS in her right eye. At the same time, the same eye showed progression of lacquer cracks when compared to images taken 2 months prior. Retinal imaging findings characteristic of MEWDS were most obvious on fundus autofluorescence, whereas alterations on color fundus photography, optical coherence tomography, fluorescein, and indocyanine green angiography were very mild, probably because of the myopia-related fundus pathology.We present a case of MEWDS co-occurring with acute progression of lacquer cracks. This adds to the increasing evidence that impaired integrity of the retinal pigment epithelium-Bruch's membrane complex may be a factor in causing MEWDS, possibly by exposing otherwise isolated antigens. The anatomy in a highly myopic eye may make it challenging to diagnose MEWDS-associated fundus changes.ZIEL: Bericht einer Assoziation von Multiple Evanescent White Dot Syndrome (MEWDS) mit akuter Progression von Lacksprüngen bei hoher Myopie. KASUISTIK: Eine 41-jährige hochmyope Patientin entwickelte am rechten Auge die typischen Zeichen, Symptome und den Krankheitsverlauf von MEWDS. Im Vergleich zu Fundusbildern, die 2 Monate zuvor aufgenommen wurden, zeigte sich am rechten Auge gleichzeitig eine Progression von Lacksprüngen. Die für MEWDS charakteristischen Netzhautbefunde waren am deutlichsten in der Fundusautofluoreszenzuntersuchung zu erkennen, wohingegen sich nur geringe Veränderungen in der Fundusfotografie, optischen Kohärenztomografie sowie in der Fluorescein- und Indocyaningrünangiografie zeigten, wahrscheinlich aufgrund der myopiebedingten Funduspathologie. SCHLUSSFOLGERUNG: Wir berichten einen MEWDS-Fall, der mit einer akuten Progression von Lacksprüngen bei hoher Myopie einhergeht. Dies bestärkt die Annahme, dass eine gestörte Integrität des retinalen Pigmentepithel-Bruch-Membran-Komplexes ein pathogenetischer Faktor bei der Entwicklung von MEWDS sein kann, möglicherweise durch Exposition von ansonsten isolierten Antigenen. Die Anatomie eines stark myopen Auges kann die Diagnose MEWDS-assoziierter Fundusveränderungen erschweren.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effect of lens extraction compared to laser peripheral iridotomy (LPI) in the treatment of acute primary angle closure (APAC).

A 28-year-old man was admitted to hospital for surgical repair of a distal femur fracture sustained during a road traffic accident. Recovery was complicated by a pulmonary embolism. Two days later, his respiratory status declined, and he was transferred to intensive care unit (ICU) for ventilatory support due to confirmed SARS-CoV-2 infection. He reported bilateral reduced vision after being discharged from ICU. Visual acuities were 6/18 right and 6/12 left. Dilated funduscopy revealed bilateral cotton wool spots and small, sparse mid-peripheral intraretinal haemorrhages (figure 1). Discrete areas of retinal pallor involving the fovea were consistent with paracentral acute middle maculopathy (PAMM), confirmed on optical coherence tomography (OCT) (figure 2). Figure 1 Fundus autofluorescence of the right eye (A) and left eye (B) showing bilateral cotton wool spots …

Background To evaluate the characteristics, treatment patterns and outcomes of acute postoperative endophthalmitis. Methods Patients presenting with acute postoperative endophthalmitis between January 2017 to December 2019 were identified from hospital records in this multicentre retrospective cohort study. Clinical records were reviewed for visual acuity (VA) at various timepoints, cause of endophthalmitis, microbiological results, treatments and complications. Results Forty-six eyes of 46 patients were included. Intravitreal injections were the leading cause of acute postoperative endophthalmitis (n = 29; 63%), followed by cataract surgery (n = 8; 17%), vitreoretinal surgery (n = 7; 15%), and secondary intraocular lens insertion (n = 2, 4%). The absolute risk of endophthalmitis was 0.024% (1:4132) for intravitreal injections, 0.016% (1:6096) for cataract surgery, and 0.072% (1:1385) for vitreoretinal surgery. The majority of patients (n = 38; 83%) had better VA at 6 months compared to presentation, although fewer (n = 13; 28%) maintained similar or better VA compared to before the precipitating surgery. Twenty-four cases yielded positive culture results, of which staphylococcus epidermidis was the most commonly isolated organism. Microbiological yield was not associated with better final visual outcomes. Patients who underwent therapeutic vitrectomy (n = 15; 33%) had poorer VA at presentation, but subsequently achieved visual outcomes comparable to those who received medical treatment alone. There was no difference in time to presentation, visual outcome and retinal detachment rates among the different causative procedures. Conclusion Intravitreal injections were the most common cause of endophthalmitis in our region, primarily because of their higher frequency compared to other intraocular procedures. In this cohort, the primary procedure had no effect on presentation, management or visual outcomes.

Background Existing research from several countries has suggested that rural-dwellers may have poorer cancer survival than urban-dwellers. However, to date, the global literature has not been systematically reviewed to determine whether a rural cancer survival disadvantage is a global phenomenon. Methods Medline, CINAHL, and EMBASE were searched for studies comparing rural and urban cancer survival. At least two authors independently screened and selected studies. We included epidemiological studies comparing cancer survival between urban and rural residents (however defined) that also took socioeconomic status into account. A meta-analysis was conducted using 11 studies with binary rural:urban classifications to determine the magnitude and direction of the association between rurality and differences in cancer survival. The mechanisms for urban-rural cancer survival differences reported were narratively synthesised in all 39 studies. Findings 39 studies were included in this review. All were retrospective observational studies conducted in developed countries. Rural-dwellers were significantly more likely to die when they developed cancer compared to urban-dwellers (HR 1.05 (95% CI 1.02 – 1.07). Potential mechanisms were aggregated into an ecological model under the following themes: Patient Level Characteristics; Institutions; Community, Culture and Environment; Policy and Service Organization. Interpretation Rural residents were 5% less likely to survive cancer. This effect was consistently observed across studies conducted in various geographical regions and using multiple definitions of rurality. High quality mixed-methods research is required to comprehensively evaluate the underlying factors. We have proposed an ecological model to provide a coherent framework for future explanatory research. Funding None.

Prediction models allow accurate estimate of individualized prognosis. Increasing numbers of models on survival of CRC patients with surgical resection are being published. However, their performance and potential clinical utility have been unclear. A systematic search in MEDLINE and Embase databases (until 9th April 2018) was performed. Original model development studies and external validation studies predicting any survival outcomes from CRC (follow-up ≥1 year after surgery) were included. We conducted random-effects meta-analyses in external validation studies to estimate the performance of each model. A total of 83 original prediction models and 52 separate external validation studies were identified. We identified five models (Basingstoke score, Fong score, Nordinger score, Peritoneal Surface Disease Severity Score and Valentini nomogram) that were validated in at least two external datasets with a median summarized C-statistic of 0.67 (range: 0.57-0.74). These models can potentially assist clinical decision-making. Besides developing new models, future research should also focus on validating existing prediction models and investigating their real-word impact and cost-effectiveness for CRC prognosis in clinical practice.

Munro and colleagues list several strategies for mitigating the negative effects of the covid-19 pandemic on surgical training.1 Of these, developing simulation opportunities for trainees is of paramount importance. The challenges of the pandemic have led to innovative developments expanding the role of simulation in ophthalmology.2 New rules around movement and social distancing have inspired adaptation of existing technology to allow remote supervision of simulation sessions.3 We are currently …

BACKGROUND To determine the magnitude of uncontrolled hypertension and smoking among patients visiting an eye clinic, and ascertain if referral to care providers is effective. METHODS Information on smoking status and blood pressure (BP) was collected among patients ≥18 years visiting an eye clinic. Those with high BP (systolic: ≥140 mm Hg and/or diastolic: ≥90 mm Hg) received a pamphlet on harms of hypertension on vision and were referred to a primary care physician. Smokers received a pamphlet on negative effects of smoking on vision and were offered referral to a tobacco quitline. Patients were followed up for referral outcome within 10 weeks from screening. RESULTS Screening: A total of participants screened included 140 (29.5%) with high BP and 31 (6.6%) current smokers. In the high BP group, 92 (66%) subjects were previously diagnosed with hypertension. Follow-up: Of the 140 participants with elevated BP, 84 (60%) responded to follow-up. Among these 84 participants, 57 (67.9%) had consulted primary care, of whom 5 (8.8%) reported being newly diagnosed with hypertension, and 11 (19.3%) reported a change in their antihypertensive prescription. Among the 31 smokers, 24 (77.4%) were willing for quitline referral. Sixteen (66.7%) of these patients responded to follow-up, 8 (50%) of whom reported participation in a smoking-cessation program with 1 patient (6.3%) successfully quitting smoking. CONCLUSIONS Nearly one-third of patients attending an eye clinic had elevated BP, and a smaller, but substantial, number of patients were current smokers. Eye clinics may serve as point for identification and referral of these patients with unmet needs.

BACKGROUND: Rurality and distance from cancer treatment centres have been shown to negatively impact cancer outcomes, but the mechanisms remain obscure.METHODS: We analysed the impact of travel time to key healthcare facilities and mainland/island residency on the cancer diagnostic pathway (treatment within 62 days of referral, and within 31 days of diagnosis) and 1-year mortality using a data-linkage study with 12 339 patients.RESULTS: After controlling for important confounders, mainland patients with more than 60 min of travelling time to their cancer treatment centre ((OR 1.42; 95% CI 1.25-1.61) and island dwellers (OR 1.32; 95% CI 1.09-1.59) were more likely to commence cancer treatment within 62 days of general practitioner (GP) referral and within 31 days of their cancer diagnosis compared with those living within 15 min. Island-dweller patients were more likely to have their diagnosis and treatment started on the same or next day (OR 1.72; 95% CI 1.31-2.25). Increased travelling time to a cancer treatment centre was associated with increased mortality to 1 year (30-59 min (HR 1.21; 95% CI 1.05-1.41), >60 min (HR 1.18; 95% CI 1.03-1.36), island dweller (HR 1.17; 95% CI 0.97-1.41).CONCLUSIONS: Island dwelling and greater mainland travel burden was associated with more rapid cancer diagnosis and treatment following GP referral even after adjustment for advanced disease; however, these patients also experienced a survival disadvantage compared with those living nearer. Cancer services may need to be better configured to suit the different needs of dispersed populations.British Journal of Cancer advance online publication, 22 June 2017; doi:10.1038/bjc.2017.180 www.bjcancer.com.

Additional information 1. Additional information on generation of drug resistant cell lines. Additional information 2. Details of sample preparation and gene expression profiling. Additional information 3. Gene expression Data. Additional information 4. PCR primer sequences. Additional information 5. Additional details of analysis and quantification of sphingosine-1-phosphatefrom cell lines using high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Additional information 6. Additional details of chemotherapy treatment of patients. Additional information 7. Pathways identified in Gene enrichment analysis (DAVID v6.7) of resistant cell lines. (PDF 725 kb)

BACKGROUND: Primary angle‐closure glaucoma (PACG) is characterized by a rise in intraocular pressure (IOP) secondary to aqueous outflow obstruction, with relative pupillary block being the most common underlying mechanism. There is increasing evidence that lens extraction may relieve pupillary block and thereby improve IOP control. As such, comparing the effectiveness of lens extraction against other commonly used treatment modalities can help inform the decision‐making process. OBJECTIVES: To assess the effectiveness of lens extraction compared with other interventions in the treatment of chronic PACG in people without previous acute angle‐closure attacks. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, one other database, and two trials registers (December 2019). We also screened the reference lists of included studies and the Science Citation Index database. We had no date or language restrictions. SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing lens extraction with other treatment modalities for chronic PACG. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methodology. MAIN RESULTS: We identified eight RCTs with 914 eyes. We obtained data for participants meeting our inclusion criteria for these studies (PACG only, no previous acute angle‐closure attacks), resulting in 513 eyes included in this review. The participants were recruited from a diverse range of countries. We were unable to conduct meta‐analyses due to different follow‐up periods and insufficient data. One study compared phacoemulsification with laser peripheral iridotomy (LPI) as standard care. Participants in the phacoemulsification group were less likely to experience progression of visual field loss (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13 to 0.91; 216 eyes; moderate certainty evidence), and required fewer IOP‐lowering medications (mean difference [MD] ‐0.70, 95% CI ‐0.89 to ‐0.51; 263 eyes; moderate certainty evidence) compared with standard care at 12 months. Moderate certainty evidence also suggested that phacoemulsification improved gonioscopic findings at 12 months or later (MD ‐84.93, 95% CI ‐131.25 to ‐38.61; 106 eyes). There was little to no difference in health‐related quality of life measures (MD 0.04, 95% CI ‐0.16 to 0.24; 254 eyes; moderate certainty evidence), and visual acuity (VA) (MD 2.03 ETDRS letter, 95% CI ‐0.77 to 4.84; 242 eyes) at 12 months, and no observable difference in mean IOP (MD ‐0.03mmHg, 95% CI ‐2.34 to 2.32; 257 eyes; moderate certainty evidence) compared to standard care. Irreversible loss of vision was observed in one participant in the phacoemulsification group, and three participants in standard care at 36 months (moderate‐certainty evidence). One study (91 eyes) compared phacoemulsification with phaco‐viscogonioplasty (phaco‐VGP). Low‐certainty evidence suggested that fewer IOP‐lowering medications were needed at 12 months with phacoemulsification (MD ‐0.30, 95% CI ‐0.55 to ‐0.05). Low‐certainty evidence also suggested that phacoemulsification may have improved gonioscopic findings at 12 months or later compared to phaco‐VGP (angle grading MD ‐0.60, 95% CI ‐0.91 to ‐0.29; TISA500 MD ‐0.03, 95% CI ‐0.06 to ‐0.01; TISA750 MD ‐0.03, 95% CI ‐0.06 to ‐0.01; 91 eyes). Phacoemulsification may result in little to no difference in best corrected VA at 12 months (MD ‐0.01 log MAR units, 95% CI ‐0.10 to 0.08; low certainty evidence), and the evidence is very uncertain about its effect on IOP at 12 months (MD 0.50 mmHg, 95% CI ‐2.64 to 3.64; very low certainty evidence). Postoperative fibrin reaction was observed in two participants in the phacoemulsification group and four in the phaco‐VGP group. Three participants in the phaco‐VGP group experienced hyphema. No data were available for progression of visual field loss and quality of life measurements at 12 months. Two studies compared phacoemulsification with phaco‐goniosynechialysis (phaco‐GSL). Low‐certainty evidence suggested that there may be little to no difference in mean IOP at 12 months (MD ‐0.12 mmHg, 95% CI ‐4.72 to 4.48; 1 study, 32 eyes) between the interventions. Phacoemulsification did not reduce the number of IOP‐lowering medications compared to phaco‐GSL at 12 months (MD ‐0.38, 95% CI ‐1.23 to 0.47; 1 study, 32 eyes; moderate certainty evidence). Three eyes in the phaco‐GSL group developed hyphemas. No data were available at 12 months for progression of visual field loss, gonioscopic findings, visual acuity, and quality of life measures. Three studies compared phacoemulsification with combined phaco‐trabeculectomy, but the data were only available for one study (63 eyes). In this study, low‐certainty evidence suggested that there was little to no difference between groups in mean change in IOP from baseline (MD ‐0.60 mmHg, 95% CI ‐1.99 to 0.79), number of IOP‐lowering medications at 12 months (MD 0.00, 95% CI ‐0.42 to 0.42), and VA measured by the Snellen chart (MD ‐0.03, 95% CI ‐0.18 to 0.12). Participants in the phacoemulsification group had fewer complications (risk ratio [RR] 0.59, 95% CI 0.34 to 1.04), and the phaco‐trabeculectomy group required more IOP‐lowering procedures (RR 5.81, 95% CI 1.41 to 23.88), but the evidence was very uncertain. No data were available for other outcomes. AUTHORS' CONCLUSIONS: Moderate certainty evidence showed that lens extraction has an advantage over LPI in treating chronic PACG with clear crystalline lenses over three years of follow‐up; ultimately, the decision for intervention should be part of a shared decision‐making process between the clinician and the patient. For people with chronic PACG and visually significant cataracts, low certainty evidence suggested that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not confer any additional benefit over phacoemulsification alone. There was insufficient evidence to draw any meaningful conclusions regarding phacoemulsification versus trabeculectomy. Low certainty evidence suggested that combining phacoemulsification with trabeculectomy does not confer any additional benefit over phacoemulsification alone, and may cause more complications instead. These conclusions only apply to short‐ to medium‐term outcomes; studies with longer follow‐up periods can help assess whether these effects persist in the long term.