Objective To characterize clinical features, management, and outcomes of pediatric macular hole (MH) and to outline an etiology-guided aid. Design A retrospective, consecutive case series. Participants Pediatric MH patients diagnosed, surgically treated, and followed at a tertiary centre (March 2012 to January 2025). Methods Clinical data (age, sex, etiology, best-correct visual acuity [BCVA], intraocular pressure, axial length, MH size, and imaging) were reviewed. Etiology was classified as traumatic, secondary, or idiopathic. Vitreoretinal techniques and adjuncts were recorded. Results Eighty-eight eyes of 88 patients were included: traumatic 51/88 (58%), secondary 25/88 (28%), and idiopathic 12/88 (14%). At baseline, idiopathic MHs had better BCVA than traumatic (p = 0.05) and secondary (p = 0.003), while secondary MHs had longer axial length than traumatic MHs (p = 0.023). Imaging patterns differed by etiology (acute-injury changes in traumatic; proliferative/tractional features in secondary; relatively “pure” in idiopathic). Surgery reflected these patterns: internal limiting membrane flap/covering in 33% of traumatic MH; multiple adjuncts in secondary eyes (laser 56% with anti-vascular endothelial growth factor/steroid/buckle/oil); and primarily inert-gas tamponade in idiopathic MH (75%). Primary complete closure was 82%; final complete closure after reintervention was 84%. Mean final BCVA improved to 0.90 logMAR (≈20/160; p < 0.001), and the proportion with BCVA >20/200 rose from 47% to 68%. Visual gains were greatest in idiopathic and traumatic. Conclusions An etiology-informed, size/edge/traction-guided approach was associated with meaningful—though limited—visual improvement and high closure. These practice-informing data support early recognition, tailored surgery, and proactive complication management; a decision aid is provided. Prospective studies are needed to standardize thresholds and validate outcomes.
OBJECTIVES:RPE65-associated Leber's congenital amaurosis (RPE65-LCA) is now treatable with a subretinal injection of voretigene neparvovec-rzyl (VN). Outcomes specific to young patients are not often reported. We present outcomes of young patients ≤21 years old with RPE65-LCA who have received VN. DESIGN:A single-centre, retrospective review of 18 patients ≤21 years old (mean age: 14.6 ± 3.4 years, 10 females) with biallelic RPE65-LCA treated with VN (mean follow-up: 14.8 ± 7.6 months). METHODS:Outcomes studied include best-corrected visual acuity (BCVA), Goldmann visual field (GVF), white full-field stimulus test (FSTw), and central retinal thickness (CRT) and ellipsoid zone width from optical coherence tomography (OCT). Thresholds for significant change were BCVA ≥0.3 logMAR, GVF ≥30%, FST ≥5 dB, and CRT ≥10%. RESULTS:While significant improvement in BCVA, GVF V4e, and III4e isopters were noted in 11%, 11%, and 39%, respectively, FSTw values improved significantly in 100%. (mean -2.8 ± 1 log, i.e., 256X). Chorioretinal atrophy (CRA) at baseline was observed in 38%, while at the last visit, some CRA was observed in all patients. The presence of nummular and/or perifoveal atrophy at baseline correlated with poorer functional outcomes. Neither postoperative elevated intraocular pressure nor return of inflammation after cessation of steroids affected functional outcomes; however, inflammation was associated with the development of nummular atrophy. CONCLUSIONS:VN treatment is safe and effective in improving retinal sensitivity in patients 21 years old or less with RPE65-LCA despite the occurrence of CRA post-treatment.
OBJECTIVE:Amid growing adoption of AI in ophthalmology, Hill-Radial Basis Function (Hill-RBF) 3.0 formula may improve refractive target prediction across diverse populations, transforming patient care. This systematic review and meta-analysis (PROSPERO: CRD42021231150) evaluated the predictive performance of the Hill-RBF 3.0 against other traditional and AI-based intraocular lens (IOL) power calculation formulas. DESIGN:Systematic review and meta-analysis. METHODS:EMBASE, MEDLINE, CINAHL, and Web of Science were searched on March 17, 2025. Eligible studies reported refractive or cataract surgeries using Hill-RBF 3.0 and at least 1 comparable formula (Barrett Universal II, EVO 2.0, Haigis, Hoffer Q, Hoffer QST, Holladay I, Ladas Super Formula AI, Kane, Olsen, Pearl-DGS, or SRK/T). Standardized mean difference (SMD) in mean absolute error (MAE) and odds ratio (OR) of achieving postoperative refraction within ±0.25, ±0.50, and ±1.00 diopters (D) were assessed. Meta-analyses were performed. RESULTS:Of 130 records screened, 31 studies were included qualitatively and 28 quantitatively. Hill-RBF 3.0 showed significantly lower MAE (SMD [95% CI]) compared to Haigis (-0.12 [-0.21 to -0.02]; p = 0.01), Holladay-1 (-0.08 [-0.15 to -0.01]; p = 0.04), and SRK/T (-0.07 [-0.14 to 0.00]; p = 0.04). Odds (odds ratio [OR; 95% CI]) of achieving ±0.50 D were higher versus Haigis (1.09 [1.01-1.19]; p = 0.03), Hoffer Q (1.11 [1.04-1.19]; p = 0.002), Holladay-1 (1.10 [1.02-1.18]; p = 0.02), and SRK/T (1.08 [1.01-1.16]; p = 0.02). Similarly, Hill-RBF outperformed these formulas within ±0.25 D, except in comparison with Holladay-1. CONCLUSIONS:Hill-RBF 3.0 achieved comparable or superior predictive accuracy over traditional and AI-based formulas, enhancing clinical workflows, refractive outcomes, and patient care.
Objective To identify genetic variants with prognostic value in uveal melanoma (UM) using targeted next-generation sequencing (NGS) and evaluate their association with metastasis and histologic subtype. Design A retrospective observational study. Methods Targeted NGS was performed on tumour samples from 69 patients with choroidal melanoma treated by enucleation. Histopathological features and clinical outcomes were reviewed. Cox regression and multivariable logistic regression analyses were used to assess the relationship between genetic variants and metastatic risk and histological subtype, respectively. Internal model validation was performed using bootstrap resampling. Results A total of 231 pathogenic variants were identified across 28 genes. In multivariable Cox analysis, larger tumour size (HR = 3.07), and higher mitotic index (HR = 1.31) were significantly associated with increased metastatic risk, along with mutations in BAP1, CHEK2, and DICER1. Internal validation yielded a corrected Harrell’s C-index score of 0.801. Logistic regression showed that BAP1 and LRP1B mutations were associated with epithelioid/mixed histology, while SF3B1 mutation was associated with spindle cell morphology. Conclusions Mutations in BAP1, CHEK2, and DICER1 are independently associated with poorer prognosis in UM, while SF3B1 defines a distinct histologic subgroup. Routine mutational profiling by targeted NGS may aid in risk stratification and follow-up of UM patients.
OBJECTIVE:To evaluate whether age ≥80 years independently influences outcomes after endoscopic dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (NLDO). DESIGN:A retrospective cohort study. PARTICIPANTS:Three hundred forty-six consecutive adults underwent standardized endonasal DCR between 2011 and 2023; 31 were ≥80 years. METHODS:Preoperative comorbidities, intraoperative variables and postoperative course were prospectively recorded. Outcomes-ostium patency, symptom relief, complications and revision-were assessed at a median of 12 months (IQR 6-24). Kaplan-Meier curves and multivariable Cox proportional-hazards models identified independent predictors. RESULTS:Octogenarians had more hypertension (64.5% vs 26.0%; p < 0.001) and hypothyroidism (25.8% vs 7.3%; p = 0.003). Silicone intubation was less common in this group (32.3% vs 54.0%, p = 0.021) but did not affect outcomes. Anatomical success was 83.9% in octogenarians versus 84.1% in younger adults (p = 0.97); functional success was 74.2 % versus 76.2% (p = 0.81). Complication (12.9 % vs 16.2 %; p = 0.64) and revision (3.2 % vs 4.1 %; p = 0.78) rates, as well as 24-month event-free survival, did not differ. Age ≥80 years was not an independent predictor of failure (Hazard Ratio: 0.93, 95% CI: 0.44-1.98). CONCLUSIONS:Despite greater systemic morbidity, very elderly patients achieved safety and efficacy equivalent to younger adults. Chronological age alone should not preclude endoscopic DCR; these real-world data support offering minimally invasive lacrimal surgery and -evidence-based counseling to an aging population.
Objective To measure the incidence and risk factors of rhegmatogenous retinal detachment (RRD) in a Canadian population from 2010 to 2023. Design A retrospective cohort study. Participants Patients with ICD-10 diagnostic code H33.0 (retinal detachment with retinal break) and controls who had cataract surgery but no prior history of detachment, age (±2 years) and sex-matched. Methods Patients reporting to the QEII Health Sciences Centre between January 1, 2010, to December 31, 2023, were included. The primary outcome was the incidence rate of RRD estimated using negative binomial regression. Generalized linear model was used to compare the risk of RRD and Cox-proportional hazards to model time to RRD following cataract surgery. Results Annual RRD incidence rates increased from 15.2 to 27.5 cases per 100,000 between 2010 and 2023. Mean axial length of RRD patients with prior cataract surgery was 25.0 (1.55) mm compared with the control population of 24.1 (1.60) mm. An increased risk of RRD was associated with each 1-mm increase in axial length (hazard ratio [HR] 1.31), male sex (HR 1.29), and per 1 year age increase (HR 1.03) post-cataract surgery. Time-to-event analyses identified that the mean time from cataract surgery to RRD was 9.43 years. Conclusions Increases in RRD cases have been seen over the last 14 years. While the total risk for RRD is still small, male sex and a 1-2 mm increase in axial length can significantly change a patient’s risk. Furthermore, the increased risk of RRD after cataract surgery is not only an early event.
Purpose To describe the clinical outcomes of combined Descemet stripping automated endothelial keratoplasty (DSAEK) and intraocular lens (IOL) exchange using the Yamane technique, and to review the literature. Methods This is a retrospective interventional case series. Included were patients with decompensated cornea and dislocated IOL, anterior-chamber IOL, or iris-claw IOL that underwent IOL exchange using the Yamane technique combined with suture pull-through DSAEK. Best-corrected visual acuity (BCVA), graft survival, and complications were evaluated at year 1. Results Twenty-four eyes from 24 patients were included. Mean age was 71 ± 14.2 years. All except 1 patient (95.8%) had concomitant issues that could limit visual outcome or success of surgery, such as glaucoma (62.5%, of which 47.0% had previously undergone glaucoma tube surgery). Mean BCVA improved from 20/590 to 20/93 1 year after surgery (p = 0.0001). Rebubbling was performed in 4 eyes (16.7%), and 2 eyes (8.3%) had graft failure requiring repeat DSAEK. None had graft rejection. Two eyes (8.3%) developed IOL issues (1 haptic-optic junction dislocation and 1 haptic-optic junction rotation), 6 eyes (25.0%) had ocular hypertension requiring topical treatment, and 1 eye had suprachoroidal hemorrhage. Conclusions Combined DSAEK and IOL exchange using the Yamane technique was shown to be a safe and effective method for visual rehabilitation in patients with decompensated cornea and anterior chamber/iris-claw/dislocated IOL. Further studies are required to evaluate the long-term stability of the graft and the IOL.
PURPOSE:Proliferative diabetic retinopathy causes severe vision loss. Although anti-vascular endothelial growth factor (VEGF) injections aid surgery outcomes, optimal timing is unclear. We evaluated the efficacy and safety of anti-VEGF injections at various perioperative time points. METHOD:This network meta-analysis comprehensively searched PubMed, Cochrane Library, Web of Science, Embase, ClinicalTrials.gov, and WHO ICTRP from inception to November 2024 for randomized controlled trials examining perioperative anti-VEGF injection. Two authors independently screened the studies, collected the data, and assessed the risk of bias. The protocol was registered with PROSPERO (CRD42024614758). RESULTS:Thirty studies involving 2 646 eyes were analyzed. Perioperative anti-VEGF treatment significantly improved postoperative best-corrected visual acuity (preoperatively >7 days: standardized mean difference [SMD] = 0.57, 95% CI: 0.01-1.13; preoperatively 3-7 days: SMD = 0.50, 95% CI: 0.29-0.70; intraoperative: SMD = 0.34, 95% CI: 0.10-0.66). It also reduced recurrent vitreous hemorrhage (intraoperative: odds ratio [OR] = 0.28, 95% CI: 0.09-0.87), and intraoperative bleeding (preoperatively >7 days: OR = 0.11, 95% CI: 0.03-0.39; preoperatively 3-7 days: OR = 0.22, 95% CI: 0.04-1.13). Additionally, it shortened surgical time (preoperatively >7 days vs preoperatively 1-3 days: WMD = -17.90, 95% CI: -29.99 to -5.81). No significant effects on silicone oil use or recurrent retinal detachment were observed. The safety profile of anti-VEGF has been found to be favourable. CONCLUSIONS:The combination of perioperative anti-VEGF injections provides several advantages. Clinicians may select the optimal timing based on individualized treatment objectives. However, because of the variability in evidence quality and the heterogeneity among the included studies, these conclusions should be approached with caution.
OBJECTIVE:To compare in detail the clinical outcome and safety of PreserFlo MicroShunt implantation versus trabeculectomy in patients with secondary open-angle glaucoma (SOAG). DESIGN/PARTICIPANTS:A retrospective study of patients with SOAG and uncontrolled intraocular pressure (IOP) who underwent PreserFlo MicroShunt implantation (PreserFlo) or trabeculectomy (TRAB) at the Medical University of Innsbruck. METHODS:We analyzed changes in IOP, use of IOP-lowering medications, complete surgical success (IOP ≤21 to ≤12 mm Hg and >6 mm Hg without medication), best-corrected visual acuity, and visual field outcomes up to 12 months postoperatively. RESULTS:Between 2014 and 2023, PreserFlo was performed in 85 eyes and TRAB in 55 eyes. Mean IOP decreased from 26.8 to 10.8 mm Hg (mean reduction 56%, 95% confidence interval 52-61%; p < 0.001) in the PreserFlo group and from 27.3 to 10.9 mm Hg (mean reduction 55%, 46-65%; p < 0.001) in the TRAB group. IOP was significantly lower in the PreserFlo group at 1-3 days and 1 week (p < 0.001 and p = 0.007, respectively). At 12 months, both groups showed similar rates of medication use (18.8% vs 11.4%; p = 0.334) and complete surgical success (e.g., ≤18 mm Hg: 76.8% vs 75.7%; p = 0.864). PreserFlo was associated with fewer needlings (hazard ratio 0.33; 0.12-0.90; p = 0.0031) and worse BCVA at month 12 (p = 0.036). CONCLUSIONS:Both PreserFlo and trabeculectomy significantly lowered IOP and reduced medication use over 12 months. PreserFlo was associated with fewer postoperative interventions, while TRAB yielded better visual acuity outcomes. Both procedures appear comparably safe and effective for treating SOAG.
OBJECTIVE:To evaluate whether semaglutide use is associated with thyroid eye disease (TED)-related outcomes among patients with autoimmune thyroiditis and type II diabetes mellitus (T2DM). METHODS:Adults with thyrotoxicosis (International Classification of Diseases [ICD-10]: E05) and T2DM were identified from the TriNetX US Collaborative Network. T2DM was defined by ICD-10 (E11) or laboratory criteria. The exposed cohort included individuals prescribed semaglutide on or after its Foood and Drug Administration approval (December 5, 2017). The control cohort included patients treated with non-glucogon-like peptide-1 receptor agonist antihyperglycemic agents without prior glucagon-like peptide-1 receptor agonist exposure. Propensity score matching (1:1) was performed using demographics, comorbidities, medications, and health care utilization variables. Five-year outcomes included: (1) TED-related diagnoses; (2) systemic corticosteroid use; (3) TED-related surgical interventions; (4) radiation treatment; and (5) teprotumumab use. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS:After matching, 23,279 patients were included per group (mean age: 60.1 years; 75% female). At 5-year, semaglutide users had lower rates of TED-related diagnoses (2.16% vs 2.82%; RR: 0.76; 95% CI: 0.68-0.86), systemic corticosteroid use (22.71% vs 26.39%; RR: 0.86; 95% CI: 0.82-0.90), TED-related surgical interventions (0.30% vs 0.42%; RR: 0.70; 95% CI: 0.51-0.96), and radiation treatment (1.17% vs 2.05%; RR: 0.57; 95% CI: 0.49-0.67). Teprotumumab use was rare and similar between groups (0.08% vs 0.08%; RR: 1.00; 95% CI: 0.52-1.92). CONCLUSIONS:Semaglutide use was associated with fewer TED-related diagnoses and treatments over 5 years, supporting a potential protective role. Further studies are warranted to confirm these associations and clarify underlying mechanisms.
OBJECTIVE:To evaluate longitudinal trends and determinants of diabetic retinopathy (DR) screening uptake over 10 years among adults with newly diagnosed diabetes in Ontario, Canada. METHODS:A population-based cohort study using linked ICES (formerly the Institute for Clinical Evaluative Sciences) administrative data, including adults aged ≥19 years with newly diagnosed diabetes between April 1, 2011, and March 31, 2020. The primary outcome was DR screening within 2 years of diagnosis. Predictors included age, sex, socioeconomic status, comorbidities, rurality, immigration status, and health system factors. Logistic regression evaluated the associations. Five-year rates and ocular complications were assessed. RESULTS:Among 691,557 individuals, 396,073 (57.3%) received DR screening within 2 years of diagnosis. Screening was more common among older adults, females, and individuals with higher comorbidity or rural residence, and less common among younger patients (OR [odds ratio]: 0.22 for age 20-39 vs ≥65; p < 0.0001), males (OR: 1.10 for females vs males; p < 0.0001), immigrants (OR: 0.98; p < 0.0001), and those in the lowest income quintile. One-year rates declined from 44.9% (2011/12) to 35.2% (2019/20), and 5-year rates from 76.8% (2011/12) to 72.4% (2017/18). DR and other ocular conditions were more often diagnosed among screened individuals. Screening dropped sharply during COVID-19, especially among younger adults. CONCLUSIONS:Despite universal health care, substantial disparities in DR screening persist across age, sex, immigration status, and socioeconomic strata. Screening rates declined over time and were further exacerbated by COVID-19. These findings underscore the urgent need for targeted, equity-oriented strategies, such as teleophthalmology and primary care integration, to improve uptake and prevent vision loss in the growing diabetic population.
OBJECTIVE:Eye care providers have a responsibility to accommodate patients with visual impairment; however, few studies have explored the accessibility of eye clinics. It is critical to involve stakeholders in these discussions to design spaces with thoughtfulness and intentionality. This study aimed to identify challenges and practical solutions for the accessibility of eye clinic design. DESIGN:An observational, qualitative study. PARTICIPANTS:Participants with visual impairment and blindness were recruited for interviews through "Get Together with Technology", an initiative through the Canadian Council of the Blind that brings together people with vision impairment to use adaptive technology. METHODS:Participants completed 45-minute semi-structured interviews using video conferencing. Audio recordings were transcribed, de-identified, coded, and analyzed for themes. RESULTS:Twenty adult participants were interviewed from across Canada. Eleven participants had a self-reported visual acuity of counting fingers or less. The most common self-reported primary diagnoses were retinitis pigmentosa (5/20) and glaucoma (3/20). Three major themes were intentionality of accommodations, confidence, and design features. Most participants with early-onset vision loss reported greater confidence in navigating eye care clinics. Participants with late-onset vision loss endorsed barriers to adapting to new skills and technologies. Participants identified challenges and practical solutions for specific clinic features, including paperwork, staff interactions, signage, obstructions, lighting, and transportation. CONCLUSIONS:This study highlighted the diverse needs and lived experiences of patients with visual impairment and blindness who access eye care services with respect to accessibility in clinic design. Through a solutions-focused worldview, this study identifies practical suggestions and modifications for health services to meaningfully accommodate patients with visual impairment.
Objective To evaluate the breadth of RPGR gene variants in a cohort of Canadian inherited retinal dystrophy patients. Design A retrospective cohort analysis. Participants We evaluated 54 subjects in Western Canada with an inherited retinal dystrophy diagnosis and confirmed variants in the RPGR gene. Methods Clinical information collected included family history, age, sex, and ethnicity. All participants underwent a full ophthalmic examination, wide-field colour fundus photography, fundus autofluorescence imaging, and visual field testing. Pathogenicity of variants was assessed by comparison to genetic databases of disease-causing variants and in silico modelling. Results Correlation of genotype with clinical phenotype established a conclusive molecular diagnosis in 34/54 cases (62.9%), with either retinitis pigmentosa (31 cases), cone-rod dystrophy (1 case) or macular dystrophy (2 cases). In the remaining cases, 18 novel RPGR variants were identified comprising 3 nonsense, 5 frameshift, 6 duplications/deletions, 3 missense and 1 splicing variant. Using in silico modelling, 3 novel variants were classified as pathogenic, and 6 were classified as likely pathogenic, increasing the diagnostic rate to 79.6%. Only 3.8% of the cohort were South Asian compared to the local population statistic of 13.5%. Ten of 13 female RPGR carriers were symptomatic and displayed moderate-to-severe phenotypic characteristics. Conclusions Through genetic testing, we identified 18 novel RPGR variants, of which 9 were determined to be pathogenic or likely pathogenic. RPGR variants were not a significant cause of retinal dystrophy in South Asians. Female RPGR carriers with visual deficits are likely to be a significant cohort for future RPGR gene therapy trials or treatment modalities.
OBJECTIVE:To assess the association between loss to follow-up (LTFU) and risk of increase in cup-to-disc ratio (CDR) among a national registry cohort of patients with primary open-angle glaucoma (POAG). DESIGN:A retrospective longitudinal cohort study. PARTICIPANTS:Patients who had a POAG diagnosis in 2014 and had CDR documented in the IRIS Registry (Intelligent Research in Sight) both in 2014 and 2019. METHODS:LTFU was defined as a calendar year or more without an encounter. Log-Poisson regression models were used to estimate the relative risk (RR) and 95% confidence intervals (CIs) for the increase in CDR. A sensitivity analysis was also conducted to address ceiling effects for patients with baseline CDR ≥0.8. MAIN OUTCOME MEASURES:An increase by ≥0.2 in CDR from 2014 to 2019. RESULTS:Among 208,517 patients, 6.9% had an increase by ≥0.2 in CDR from 2014 to 2019. While most patients (81.6%) maintained follow-up every year, 16.1% were LTFU for 1-2 years, and 2.3% were LTFU for 3-4 years. A lapse of 3-4 years was associated with a 15% higher risk of increase in CDR (adjusted RR [aRR] = 1.15, 95% CI: 1.00-1.32) compared to no lapse in care after accounting for age, sex, race, insurance, smoking status, glaucoma severity, baseline intraocular pressure (IOP), and baseline CDR. For patients with CDR ≥ 0.8 at baseline, risk of increase in CDR by ≥0.05 was also associated with LTFU (aRR = 1.34, 95% CI: 1.11-1.60; lapse of 3-4 years compared to no lapse). CONCLUSIONS:LTFU is an independent risk factor for an increase in CDR among patients with POAG.
OBJECTIVE: To evaluate the intraocular pressure (IOP)-lowering effect, adverse event profile, and risk factors for failure of an ab externo microshunt combined with phacoemulsification after 1 year of follow-up. DESIGN: A retrospective, single-center, interventional cohort study. PARTICIPANTS: One hundred nineteen consecutive glaucomatous eyes of 97 patients with an IOP above target or progressing on maximal medical therapy. METHODS: All eyes underwent ab externo microshunt surgery with mitomycin C in combination with phacoemulsification from July 2015 to June 2019. MAIN OUTCOME MEASURES: Primary outcome was complete success, defined as (1) no 2 consecutive IOP readings >17 mm Hg or IOP <6 mm Hg with >2 lines of vision loss, (2) at least 20% IOP reduction from baseline, and (3) on no medications. Secondary outcomes included upper IOP thresholds of 14 mm Hg and 21 mm Hg, qualified success (with medications), change in IOP, medications, visual outcomes, complications, interventions, and reoperations. RESULTS: At 1-year, complete success was achieved in 67.5% of eyes and qualified success in 79.8%. The median best-corrected vision acuity improved from 0.4 (interquartile range [IQR] 0.2-0.7) at baseline to 0.14 (IQR 0.1-0.3) at 1 year (p < 0.0001), with 93.2% having the same or improved vision. The most common complications were shallow anterior chamber (10.1%), iritis (9.2%), and choroidal detachment (8.4%). Needling was required in 24.4% of the eyes. Reoperation was required in 5.9% of the eyes. CONCLUSIONS: The ab externo SIBS microshunt demonstrates reasonable rates of complete and qualified success at 1 year, decreased IOP and medication use, good visual outcomes, and few reoperations when performed in combination with phacoemulsification.
OBJECTIVE:To develop a surgical assessment tool to evaluate the breadth of surgical procedures in which ophthalmology residents are required to gain competence and to validate this tool for cataract surgery. DESIGN:A questionnaire development study. PARTICIPANTS:Ophthalmology residents and faculty at the University of Ottawa. METHODS:The Canadian Ophthalmology Assessment Tool for Surgery (COATS) was developed by a group of experts by modifying a previously validated assessment tool, the Ottawa Surgical Competency Operating Room Evaluation, and consists of 6 Likert scale items, 1 yes or no question assessing independence and 2 open-ended questions for narrative feedback. During a 2-year period, residents were evaluated on the performance of cataract surgery using the COATS. The primary outcome was the total COATS score, defined as the sum of the Likert scale items. RESULTS:A total of 165 COATS assessments were collected across 5 residents. Mean total COATS scores were lower for the first 2 months of training compared with the last 3 months of training (4.33 ± 0.25 vs 4.81 ± 0.03; p = 0.01; Cohen's d = 0.25) and for procedures where the resident was rated as "not independent" versus "independent" (4.26 ± 0.13 vs 4.74 ± 0.06; p = 0.006; Cohen's d = 0.13). There was a significant correlation between the number of cataract surgeries performed and the mean total COATS score (Pearson r = 0.20; p = 0.02). Forty-five COATS assessments per resident were required to obtain an overall reliability of 0.70, the accepted threshold for low-stakes assessments. CONCLUSIONS:The COATS is a valid tool for the assessment of surgical competence in cataract surgery. There is also evidence that it is a reliable tool when completed multiple times per resident over the course of training.
Purpose Retinopathy of prematurity (ROP) is the leading cause of childhood blindness worldwide. While choroidal involution has been described in animal models, choroidal perfusion in premature infants remains poorly characterized because of limited use of intravenous fluorescein angiography (IVFA). Methods This retrospective study systematically analyzed IVFAs performed post-treatment in patients with ROP at the Hospital for Sick Children between 2011 and 2020. Eligible patients had received intravitreal bevacizumab or laser photocoagulation, and only transiting eyes were included to allow complete IVFA phase analysis. Three independent experts graded each IVFA for image quality, presence of delayed choroidal perfusion during the arteriovenous phase, and its location (central, peripheral, or multifocal). Inter-rater reliability was assessed using Fleiss’s κ. Results Of 79 IVFAs reviewed, 74 met quality criteria. The cohort had an average birth weight of 602.6 g and a gestational age of 24.0 weeks. Most (63.5%) had zone I, stage 3+ ROP. IVFAs were conducted at a corrected age of 7.5 months. Delayed choroidal perfusion was found in 64 eyes (86.5%), predominantly multifocal. Only 2 eyes had normal perfusion. Inter-rater agreement was high (κ = 0.85). Conclusions Delayed choroidal perfusion is common and persistent in treated ROP patients. To our knowledge, this is the largest IVFA series that systematically describes this underrecognized feature with implications for long-term vision.
OBJECTIVE:To quantify the pediatric ophthalmology workforce density, travel burden, and socioeconomic inequities across all 293 Canadian census divisions (CDs). DESIGN:Cross-sectional geospatial study. PARTICIPANTS:A national database of practicing pediatric ophthalmologists in Canada (95 clinicians, 102 sites) and the 2021 Census counts of residents <18 years and median after-tax household income for all CDs. METHODS:For each CD, we calculated providers per 100,000 children, the straight-line distance to the nearest pediatric ophthalmology practice, and the 30- and 60-minute travel-time access. We defined 2 measures of underservice: (1) provider-absence desert, which is a CD with 0 resident pediatric ophthalmologists; and (2) travel-access desert, which is a CD lying outside a 30-minute drive-time catchment. RESULTS:The unweighted mean provider rate was 0.47 ± 3.82 per 100,000 children. 269 CDs (91.8%) had no resident pediatric ophthalmologist (provider-absence deserts). Separately, drive-time modeling showed that 215/293 CDs (73.4%) and 4,178,025 (41.4%) children lay entirely outside a 30-minute road network catchment (travel-access deserts). The median straight-line distance to the nearest clinic was 124.1 km (interquartile range: 57-251). Seventy-four CDs (25.3%) were ≥250 km away. Access worsened with lower income and greater rurality: the lowest-income quintile had 86.9% of children living beyond 30 minutes, versus 16.2% in the highest-income quintile. CONCLUSIONS:Timely treatment of childhood eye diseases hinges on geographic access to pediatric eye-care clinicians, yet 2 in 5 Canadian children live over 30 minutes from pediatric ophthalmologists, and 90% of CDs have no resident pediatric ophthalmologist at all. These provider-absence and travel-access deserts cluster in the lowest-income and most rural regions, signalling an urgent equity gap.
Objective: To evaluate the real-world effectiveness and safety of topical insulin (25 IU/mL) in patients with neurotrophic keratopathy (NK) across multiple etiologies. Methods: We retrospectively reviewed 29 consecutive eyes of 28 patients with neurotrophic keratopathy treated with topical insulin at a single center. The primary outcome was complete epithelial healing for stages 2 and 3 NK; for stage 1, success was prespecified as improvement in corneal staining and epithelial integrity. Statistical analysis included survival analysis and multivariable logistic regression with Firth penalization. Results: Twenty-nine eyes with a mean follow-up of 32.7 weeks were included. Most common etiologies were infectious (51.7%), including herpes simplex virus (24.1%) and varicella zoster virus (20.7%). Twenty-three eyes had stages 2 or 3 NK. Among eyes with stages 2 and 3 NK, complete epithelial healing occurred in 18/23 (78.3%, 95%; CI: 58.1-90.3%), with a median healing time of 33.5 days (IQR: 15.8-81.8). The cumulative healing rate at 8 weeks was 43.5%. Healing success was not significantly associated with defect size or etiology. Among 8 patients who discontinued insulin after healing, recurrence occurred in 1 case (12.5%) and resolved upon treatment resumption. One patient developed mild punctate keratopathy that resolved with continued therapy. Conclusions: Topical insulin demonstrated substantial healing efficacy for neurotrophic keratopathy across diverse etiologies, with a favourable safety profile and low recurrence rate. Although healing may be slower than FDA-approved alternatives, the dramatic cost difference suggests insulin may be a cost-effective first-line therapy for refractory cases. This represents one of the largest multietiological case series of insulin therapy for neurotrophic keratopathy reported to date.
Objective Vitreomacular traction is a common presentation that can benefit from surgical intervention. The decision to peel the internal limiting membrane (ILM) is made at the discretion of the operating surgeon. We describe a large cohort of eyes that had surgery with or without ILM peeling to give more evidence for the decision-making process. Design A retrospective cohort study. Participants Eyes with the diagnosis of vitreomacular traction (VMT) that underwent surgery between January 1, 2016, and January 1, 2025, at a group retina practice in Edmonton, Canada. Methods Eyes at a single center underwent vitrectomy surgery for the treatment of VMT with or without peeling of the ILM. Baseline visual and anatomic measures were captured and compared to postoperative findings. The main outcome measures were visual acuity and anatomic outcomes postsurgery. Complication rates were also captured. Results A total of 250 surgeries were performed during the study period. There was a significant improvement in vision in all eyes (0.19 logMAR). There was no difference in visual improvement when comparing ILM peeling versus ILM sparing. There was better anatomical resolution in cases that had sparing of the ILM. Complication rates were low with no difference in secondary macular hole formation when comparing ILM peeling to ILM sparing. Conclusions Pars plana vitrectomy with or without peeling of the ILM is an effective treatment for symptomatic VMT. There may be better anatomic preservation with sparing of the ILM secondary to less surgical manipulation. Complication rates are low regardless of surgical technique.
