Objective To evaluate visual outcomes in children operated for non-syndromic craniosynostosis at preschool age, in order to elucidate long-term ophthalmological effects and guide treatment and screening strategies. Methods A cohort of 89 children (63 boys) with various types of non-syndromic craniosynostosis operated at Uppsala Craniofacial Centre between 2012 and 2019 and an age-matched control group of 33 healthy children underwent ophthalmological evaluations at age 5. High-contrast visual acuity (HCVA), crowding ratio, low-contrast visual acuity (LCVA), colour vision and stereo acuity were examined using standardised protocols. Statistical analyses comparing outcomes across craniosynostosis subtypes and between the study group and control group were conducted. Results Distance HCVA and LCVA were lower in children who underwent operation for unilateral coronal craniosynostosis, mainly due to the higher prevalence of strabismus and refractive error on the side contralateral to the fused suture. Amblyopia and absence of measurable stereoacuity were also more frequent in this subtype. Crowding was common in the craniosynostosis group. Near HCVA was generally lower in all craniosynostosis subtypes compared with controls. Conclusion Long-term visual outcomes assessed at preschool age varied in children operated for non-syndromic craniosynostosis. Unicoronal craniosynostosis had the greatest risk of visual impairment. Tailored screening is needed in order to address the ophthalmological challenges associated with different craniosynostosis subtypes.
Objective To evaluate the independent and combined effects of age, diabetes and pseudophakia on endothelial cell density (ECD), assessed both as a continuous measure and as a binary outcome using a commonly used reference threshold of <2000 cells/mm². Methods and analysis This retrospective, observational, cross-sectional study analysed 681 donor corneas from 350 individuals recorded in the Rabin Medical Center, between 2014 and 2024. Baseline donor variables included age at donation, sex, diabetes status and lens status. ECD was measured centrally using Konan CellChek specular microscopy, which quantifies ECD based on manual marking of central endothelial cell centres. Generalised estimating equations were used to account for within-donor clustering, modelling ECD as both continuous and binary variables. Potential effect modification by pseudophakia was assessed in stratified models. Results Mean donor age was 62.8 years; 37.1% had diabetes and 22.8% were pseudophakic. Diabetes was associated with lower ECD overall (β = –106 cells/mm²; 95% CI –205 to –7) and with increased odds of ECD <2000 (OR=1.91; 95% CI 1.13 to 3.21). However, this effect was only significant in non-pseudophakic eyes. Pseudophakia (OR=2.88; 95% CI 1.80 to 4.63) and older age (OR per year=1.05; 95% CI 1.03 to 1.07) were consistently associated with lower ECD and a higher likelihood of falling below threshold. Conclusion Older age and pseudophakia were independently associated with increased risk of low ECD. In subgroup analyses, diabetes was linked to lower ECD only in non-pseudophakic eyes. However, formal statistical testing for interaction between diabetes and lens status was not significant.
Objective To evaluate the estimated lens diameter (eLD) of the crystalline lens in a large European cohort.Methods and analysis Data sets from an Austrian population acquired between 2020 and 2022 were analysed in this study. Measurements included optical biometry (IOLMaster 700, Carl Zeiss Meditec AG, Germany) as well as anterior segment optical coherence tomography (CASIA2, Tomey, Japan). For eLD prediction, three different machine learning approaches were implemented.Results In total, 2352 eyes of 2352 patients were included in this study. The eLD was normally distributed with a mean value of 10.18±0.56 mm, showing a statistically significant difference (p=0.008) between females and males (10.16±0.54 mm and 10.22±0.57 mm, respectively). There was a low but significant correlation (p<0.01 for all) with age (r=0.246), lens thickness (r=0.265), white-to-white (r=0.122), corneal radii (r=0.090), axial eye length (r=0.092), anterior chamber depth (r=−0.060), decentration (r=−0.087) and tilt (r=−0.159), respectively. Subanalysis of short and long eyes yielded no significant difference in eLD. For eLD prediction, age and lens thickness appeared to be relevant parameters, with all three models demonstrating low predictive accuracy.Conclusion The crystalline lens diameter followed a normal distribution with no significant differences between short and long eyes. All three models demonstrated low predictive accuracies, suggesting that reliable prediction of eLD is currently not attainable.
Aims To establish consensus-based guidance on optimising anti-vascular endothelial growth factor (VEGF) and corticosteroid use in centre-involving diabetic macular oedema (CI-DMO).Methods A two-round modified Delphi study was conducted among medical retina (MR) specialists in the National Health Service in England. In total, 82 statements were developed by a steering group and rated by a wider Delphi panel using a four-point Likert scale. Consensus was predefined as ≥75%.Results In rounds one and two, 30 and 39 MR specialists responded to the survey, respectively. In total, consensus was achieved for 64/82 statements (78%). Key outcomes were consensus on the value of personalised treatment strategies, consensus of MR specialists to validate a definition of non-response to intravitreal treatment for DMO as a reduction in central retinal thickness (CRT) by ≤10% and a suboptimal response as a reduction in CRT by 10–20% (these thresholds were adapted from those proposed by Downey et al). Early evaluation of anti-VEGF treatment response should be made at 3–6 months and after trying two different types of anti-VEGF agents. The panel reached moderate consensus that corticosteroid therapy may be considered after 9–12 months in patients with persistent suboptimal response or high treatment burden. The panel also supported consideration of transition to sustained-release corticosteroid therapy in selected patients demonstrating a positive response to short-acting corticosteroids.Conclusions This Delphi study provides a consensus-based framework to support personalised treatment decisions in CI-DMO, highlighting the importance of timely optimisation of anti-VEGF and corticosteroid therapies in cases of suboptimal response and non-response. However, as these recommendations are derived from expert consensus rather than prospective clinical validation and all panellists were from England, generalisability to other healthcare settings may be limited. Additionally, patient representatives were not included, and the recommendations require validation in clinical practice.
Objective To identify symptom-based subgroups in Sjögren’s disease using patient-reported data and explore differences in symptom burden, functional impact, psychological distress and healthcare priorities.Methods and Analysis This secondary analysis used cross-sectional data from a patient co-designed online survey conducted between June and September 2022. Individuals self-identifying as living with Sjögren’s disease (diagnosed or symptomatic) were eligible to participate. Latent class analysis was applied to 24 patient-reported symptom variables. European Alliance of Associations for Rheumatology (EULAR) Sjögren’s Syndrome Patient Reported Index and the Hospital Anxiety and Depression Scale were used in post hoc analyses to characterise and compare classes.Results A total of 296 respondents were included. Four symptom-based subgroups were identified: a sicca-predominant low-burden group (Class 1), a fatigue–dryness dominant group (Class 2), a musculoskeletal–cognitive group (Class 3) and a multisystem high-severity group (Class 4). Symptom burden, psychological distress and functional impact differed significantly across classes (all p<0.001). Inability to work increased from 3.4% in Class 1 to 33.9% in Class 4 (p<0.001). Higher-burden classes also reported greater unmet healthcare needs. Urgent need for effective treatments increased from 56% in Class 1 to 86% in Class 4 (p=0.0031), while urgent need for diagnostic testing increased from 38% to 68% (p<0.0001). Improved education of doctors and other healthcare professionals was consistently identified as a priority for improving care across all classes.Conclusion Patient-reported data identified clinically interpretable symptom-based subgroups in Sjögren’s disease that differed in symptom burden, psychological distress, functional impact and perceived unmet healthcare need. These findings support multidimensional patient-reported assessment for characterising disease heterogeneity and informing patient-centred care. Limitations include the cross-sectional design and reliance on self-reported data.
OBJECTIVES:To evaluate postoperative changes in ocular blood flow velocity and waveform parameters measured by laser speckle flowgraphy (LSFG) following trabeculectomy (TLE) in patients with glaucoma. METHODS AND ANALYSIS:This retrospective study included 80 eyes of 80 patients with glaucoma who underwent TLE and underwent LSFG examinations before and at 1, 3 and 6 months after surgery. LSFG-derived blood flow velocity parameters (mean blur rate (MBR) in MBR of vascular area (MV) and MBR of tissue area (MT), area ratio of blood speed and vascular cloudiness) and waveform parameters (blowout time, blowout score (BOS), skew, acceleration time index, rising rate, falling rate, flow acceleration index (FAI), resistivity index (RI) and fluctuation) were longitudinally evaluated using linear mixed-effects models. RESULTS:Intraocular pressure (IOP) significantly decreased from 18.3 mm Hg preoperatively to 10.1, 10.0 and 9.9 mm Hg at 1, 3 and 6 months after TLE, respectively (all p<0.01). MV significantly decreased at all postoperative time points (all p<0.01), whereas MT showed a mild decrease only at 6 months (p=0.023). Among waveform parameters, BOS significantly increased postoperatively (all p<0.05), whereas FAI, RI and fluctuation significantly decreased at all postoperative time points (all p<0.01). IOP measured at each visit was independently associated with FAI and fluctuation, whereas age, mean deviation (MD) and axial length (AL) were associated with selected blood flow velocity and waveform parameters. CONCLUSION:These findings suggest that postoperative changes in ocular haemodynamics reflect the combined influence of postoperative IOP, patient age, MD and AL.
Purpose To present an up-to-date summary of the association between ocular shape and myopia. Methods We systematically searched PubMed, Embase, Web of Science, the Cochrane Library, CNKI and Wanfang from June 2009 to September 2025 for cross-sectional and cohort studies examining the association between ocular shape and myopia (PROSPERO: CRD42024558271). The Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality were used to evaluate the quality of included studies. Results Thirty-four studies were included. Ocular growth appears relatively uniform in non-myopic eyes whereas myopic eyes tend to show non-uniform expansion. Greater myopia is associated with asymmetric changes in both anterior and posterior ocular shape. Highly myopic eyes frequently display spheroid shapes with equatorial pyriform contours and macular staphylomas, with more pronounced posterior deformities linked to a higher risk of myopic complications. Longitudinal evidence suggests that baseline ocular shape may be associated with subsequent ocular morphological changes and myopia progression. Conclusions Ocular shape is closely associated with myopia and myopic retinopathy. Existing studies remain mostly observational and heterogeneous, with small sample sizes in some studies limiting causal inference and precluding meta-analysis. Future studies are needed to better understand the potential value of ocular shape in myopia control. PROSPERO registration number CRD 42024558271.
Macular disease is the leading cause of vision loss in the United Kingdom, affecting nearly 1.5 million people. Vascular endothelial growth factor (VEGF) has a major role in the onset and progression of vision-threatening macular conditions such as neovascular age-related macular degeneration, diabetic macular oedema and retinal vein occlusion. Anti-VEGF treatments, given by intravitreal injection, can prevent vision loss and may improve vision but must be started quickly before sight loss is irreversible. Informed by an observational study using Hospital Episode Statistics and the Emergency Care Data Set in England and a Costed Integrated Patient Scenario, we identify issues within the current pathway in England. Our key recommendations to optimise care and improve patient outcomes include: (1) increasing public awareness of macular disease to reduce late presentation; (2) ensuring the right patients are seen in the right place at the right time by improving quality and priority of optometrist referrals and by specialists directing patients with conditions such as diabetes and hypertension to community optometrists in the first instance; (3) planning for current and future demand and capacity using innovative solutions to manage expected increases in medical retina conditions and (4) ensuring patient-centred care. Our evidence should encourage National Health Service organisations at all levels to review macular disease pathways to address immediate issues and plan for the future. A shift in care delivery is needed, embracing scalable sustainable solutions, earlier diagnosis and treatment, improved access to more durable therapies, wider adoption of digital technologies and care closer to home.
Objective To compare the efficacy of current treatments for retinitis pigmentosa (RP)-associated macular oedema using network meta-analysis (NMA).Methods and analysis Electronic databases were searched for studies reporting changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT). A frequentist NMA was performed and treatment hierarchies were estimated using the surface under the cumulative ranking curve.Results 12 studies were included to compare the following: oral acetazolamide 500 mg/day, oral methazolamide 50–100 mg/day, topical dorzolamide 2% three times daily, topical ketorolac 0.5% four times daily, intravenous umbilical cord mesenchymal stem cells (UCMSCs; single administration of 3×10⁶ cells), intravitreal dexamethasone implant (DEXi) 0.7 mg, intravitreal triamcinolone acetonide (IVTA) 4 mg, sub-Tenon TA (STTA) 20 mg, intravitreal bevacizumab 1.25 mg and intravitreal ranibizumab 0.5 mg. Regarding changes in BCVA at 3–4 months, oral carbonic anhydrase inhibitors (CAIs) showed greater BCVA improvement compared with anti-vascular endothelial growth factor (anti-VEGF) therapies; however, no intervention demonstrated statistically significant superiority in BCVA at 12 months. At 3–4 months, DEXi, acetazolamide, methazolamide and dorzolamide demonstrated comparable CMT reduction and outperformed anti-VEGF therapies, IVTA, STTA, intravenous UCMSC and control. By 12 months, dorzolamide (vs acetazolamide: −169.50 µm (95% CI −331.83 to −7.17) and vs methazolamide: −185.49 µm (95% CI −354.35 to −16.63)) and DEXi (vs acetazolamide: −147.00 µm (95% CI −206.58 to −87.42) and vs methazolamide: −162.99 µm (95% CI −238.56 to −87.42)) provided significantly greater CMT reduction than acetazolamide and methazolamide.Conclusions CAIs and DEXi demonstrated the greatest long-term anatomical benefit for RP-associated macular oedema, whereas durable BCVA gains remained limited across available therapies. While oral and topical CAIs showed comparable short-term efficacy, topical dorzolamide and DEXi provided greater long-term CMT reduction than oral CAIs. Given the limited number of studies and small sample sizes, these findings should be interpreted cautiously and validated in larger randomised controlled trials.
Background/aims Reticular pseudodrusen (RPD) are increasingly recognised as a distinct phenotype in the age-related macular degeneration (AMD) disease spectrum. This study investigates the association between RPD and cardiovascular outcomes, specifically myocardial infarction (MI) and stroke in the UK Biobank (UKBB).Methods Retrospective analysis of UKBB participants (n=2010). A validated deep learning framework identified and quantified subjects with RPD, drusen and controls on optical coherence tomography. Five retina specialists validated the artificial intelligence findings. Multivariable logistic regression models assessed the association between RPD/drusen and stroke, MI and combined MI/stroke, adjusting for age, sex, high-density lipoprotein cholesterol/low-density lipoprotein cholesterol ratio and smoking history.Results The study cohort included 71 subjects with pure RPD, 401 with pure drusen, 368 with both and 1170 controls. Univariable analysis showed that for every 20 RPD lesions, the OR for stroke increased by 1.02 (95% CI 1.00 to 1.04, p=0.028). The mean number of RPD per patient in this cohort was 199, indicating an increased stroke risk of 20%. Multivariable analysis showed a significant association between RPD load and stroke risk (OR 1.02, 95% CI 1.00 to 1.04, p=0.042) after adjustment for confounders. No significant association was found between drusen and stroke or between RPD/drusen and MI.Conclusion Increased RPD load is associated with a higher risk of stroke, independent of traditional cardiovascular risk factors. Drusen did not have similar associations, suggesting that RPD may represent a distinct disease entity. Evaluating cardiovascular risk in patients with numerous RPD might be advisable. Further prospective studies are needed to validate these findings and explore the underlying mechanisms.
OBJECTIVE:To investigate the relationship between photopic pupil size, refractive state and foveal anatomy in healthy adults, in the context of emmetropisation and myopia. METHODS AND ANALYSIS:In this cross-sectional study, pupil sizes were recorded in 80 healthy adults (28±8 years/55 women) using a custom-built high-resolution pupil tracker (0.03 mm/pixel). Daylight lamps provided two high-luminance conditions (6.5k and 10k cd/m²). Objective refraction and axial length were measured, and additionally high-resolution optical coherence tomography (OCT) was applied to record retinal volume scans of the fovea. OCT B-scans were automatically segmented for the internal limiting membrane and retinal pigment epithelium layers by the instrument algorithm. Additionally, the ellipsoid and phagosome zones defining the outer segment lengths were determined by a custom-made algorithm. Associations between photopic pupil size, refractive state, axial length and foveal metrics were analysed with correlation and multivariable regression. RESULTS:Photopic pupil sizes at 6.5k cd/m² ranged from 1.77 to 3.38 mm (2.33±0.26 mm). Spherical equivalent of refraction ranged from -9.4 to +4.9 D (-1.24±2.29 D), and axial length ranged from 21.0 to 27.0 mm (23.9±1.2 mm). Photopic pupil size was significantly correlated with axial length and refractive state (all p≤0.01), although the explained variance was modest (R2 up to 0.09). Outer segment length and foveal hill distance were significantly associated with refractive state (all p<0.05). CONCLUSION:The association of photopic pupil size with axial length and refractive state, alongside foveal parameters being linked to refractive state but not to pupil size (exception: nasal hill height), suggests a potential interplay between foveal architecture and emmetropisation. Further investigation via longitudinal studies of children will be required. The main limitation of this study is the under-representation of high-myopes.
