touchREVIEWS in Ophthalmology

Matossian C.

Schefler A.C., Yu H.J.

Khandelwal S.S., Houser K., Marshall B., Le N.T.

When vitreoretinal and anterior segment surgeons collaborate to perform concomitant cataract-vitreoretinal surgery (also known as phacovitrectomy) in the appropriate clinical setting, combined surgery can expedite visual recovery, improve the view and surgical access to the retina in cases with significant cataract, avoid multiple rounds of anaesthesia and reduce the financial burden on the patient. While combined surgery overcomes several limitations of sequential surgery, it is important to understand that phacovitrectomy may be associated with increased postoperative inflammation and less predictable refractive outcomes. We typically recommend combined phacovitrectomy in patients with significant cataract and vitreoretinal pathology, especially if the cataract impairs the view to the retina or if the patient is too ill to undergo several rounds of anaesthesia. In patients with high refractive expectations who have an early cataract or mild retinal pathology, combined surgery is not likely to be a viable or reasonable management option.

Corson T.W.

Powell W., Swartz T.S.

Reproxalap is a reactive aldehyde species inhibitor. This article investigates reproxalap’s ability to control ocular inflammation in non-infectious uveitis, allergic conjunctivitis and dry eye disease. Clinical trials for reproxalap were reviewed for efficacy and tolerability. Reproxalap appears to be an effective treatment for dry eye disease, with satisfactory tolerability.

Liu T.A., Koseoglu N.D.

Deep learning is a state-of-the-art machine learning technique used in medical image analysis. In recent years, there has been a growing interest in applying deep learning methods to perform prediction and prognostication tasks. Broadly speaking, these applications can be characterized as structure-structure prediction, structure-function prediction, disease onset/progression prediction and treatment response prediction. This review aims to summarize the most recent studies in this area, with a particular focus on age-related macular degeneration, diabetic retinopathy and glaucoma.

Torres-Netto E.A., Hafezi N.L., Kollros L., Hillen M., Hafezi F.

Corneal cross-linking (CXL) can halt ectasia progression and involves saturating the stroma with riboflavin, followed by ultraviolet-A (UV-A) light irradiation. This generates reactive oxygen species that covalently cross-link together stromal molecules, strengthening the cornea. The ‘Dresden protocol’ left a 70 µm uncross-linked region at the base of the stroma to protect the corneal endothelium from UV damage; however, this limited CXL to corneas ≥400 µm. Approaches made to overcome this limitation involved artificial corneal thickening to ≥400 μm through swelling the stroma with hypo-osmolaric riboflavin, applying riboflavin-soaked contact lenses during UV irradiation or leaving ‘epithelial islands’ over the thinnest corneal regions. The drawbacks to these three approaches are unpredictable swelling, suboptimal stiffening and unpredictable cross-linking effects, respectively. Newer approaches adapt the irradiation protocol to the cornea to deliver CXL that maintains the 70 μm uncross-linked stroma safety margin. The sub400 protocol employs an algorithm that models the interactions between UV-A energy, riboflavin, oxygen diffusion and stromal thickness. It requires only corneal pachymetry measurements at the thinnest point and the selection of the appropriate UV irradiation time from a look-up table to cross-link corneas as thin as 200 µm safely and effectively.

Brant A., Leng T.

Thakur S., Ichhpujani P.

There are several barriers to patient adherence in glaucoma treatment, such as complex dosing regimens, side effects and difficulties with eyedrop administration. This article discusses these challenges, and how they have led to the development of novel sustained-release platforms for glaucoma medications. These platforms include extraocular and intraocular options, such as wearable ocular surface devices, punctal plug systems, subconjunctival injections and intracameral implants. In particular, we focus on the iDose® TR (Glaukos, San Clemente, CA, USA) sustained-release travoprost titanium implant. It is a particularly promising option, which continuously elutes travoprost at therapeutic levels over an extended period. Phase III trial results have shown its efficacy in lowering intraocular pressure. Notably, the implant typically lasts for around 4–5 years and can be safely exchanged with a new one after it finishes its therapeutic effect. This advancement in glaucoma treatment offers a new alternative to traditional treatment modalities. Real-world trials are needed to shed more light on the efficacy and safety profile of iDose TR.

Singh R.P., Chong D.D., Wu A.K.

Anti-vascular endothelial growth factor (anti-VEGF) injections are a mainstay of treatment for retinal vascular diseases such as neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DMO) and retinal vein occlusion. While anti-VEGF monotherapy has helped improve visual outcomes in patients with these conditions, the need for frequent injections and follow-up visits, as well as the varying response to therapy are notable shortcomings. To address this, novel therapies have been investigated as adjuncts or alternatives to anti-VEGF monotherapy. One such therapy is faricimab, the first US Food and Drug Administration-approved intravitreal injection designed to target both VEGF-A and angiopoietin-Tie-2 for the treatment of nAMD and DMO. Clinical trial data thus far support that faricimab produces non-inferior visual and anatomical outcomes to standard anti-VEGF therapy, with longer durability, in these diseases. In this review, details regarding faricimab’s molecular development, clinical trial outcomes, and its prospect as the newest drug in the treatment landscape for retinal diseases will be discussed.