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Tele-Ophthalmology for Age-Related Macular Degeneration and Diabetic Retinopathy Screening: A Systematic Review and Meta-Analysis.
Kawaguchi, A, Sharafeldin, N, Sundaram, A, Campbell, S, Tennant, M, Rudnisky, C, Weis, E, Damji, KF
Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2018;(4):301-308
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Abstract
BACKGROUND To synthesize high-quality evidence to compare traditional in-person screening and tele-ophthalmology screening. METHODS Only randomized controlled trials (RCTs) were included in this systematic review and meta-analysis. The intervention of interest was any type of tele-ophthalmology, including screening of diseases using remote devices. Studies involved patients receiving care from any trained provider via tele-ophthalmology, compared with those receiving equivalent face-to-face care. A search was executed on the following databases: Medline, EMBASE, EBM Reviews, Global Health, EBSCO-CINAHL, SCOPUS, ProQuest Dissertations and Theses Global, OCLC Papers First, and Web of Science Core Collection. Six outcomes of care for age-related macular degeneration (AMD), diabetic retinopathy (DR), or glaucoma were measured and analyzed. RESULTS Two hundred thirty-seven records were assessed at the full-text level; six RCTs fulfilled inclusion criteria and were included in this review. Four studies involved participants with diabetes mellitus, and two studies examined choroidal neovascularization in AMD. Only data of detection of disease and participation in the screening program were used for the meta-analysis. Tele-ophthalmology had a 14% higher odds to detect disease than traditional examination; however, the result was not statistically significant (n = 2,012, odds ratio: 1.14, 95% confidence interval (CI): 0.52-2.53, p = 0.74). Meta-analysis results show that odds of having DR screening in the tele-ophthalmology group was 13.15 (95% CI: 8.01-21.61; p < 0.001) compared to the traditional screening program. CONCLUSIONS The current evidence suggests that tele-ophthalmology for DR and age-related macular degeneration is as effective as in-person examination and potentially increases patient participation in screening.
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Physical activity, visual impairment, and eye disease.
Ong, SR, Crowston, JG, Loprinzi, PD, Ramulu, PY
Eye (London, England). 2018;(8):1296-1303
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Abstract
Numerous studies have demonstrated physical activity is a strong factor in overall health and well-being, and a growing body of literature, reviewed herein, suggests that several eye conditions, including glaucoma, age-related macular degeneration, and diabetic retinopathy, are associated with lower activity levels. Likewise, physical activity levels are lower in persons with worse vision. Research in this area has utilized both self-reported physical activity measures as well as objective measures of activity (i.e., accelerometers), each of which have their own strengths and limitations. Putative mechanisms explaining the association of various eye conditions with physical activity are discussed. It is possible that activity restriction occurs as a downstream consequence of eye disease/visual impairment, that activity restriction causes eye disease/visual impairment, or that causality is bidirectional; evidence supporting each of these theories is put forth. An improved understanding of the relationship between physical activity and eye disease will highlight potential secondary health risks resulting from eye disease, and can help determine whether activity might serve as a readily available preventative measure to prevent specific eye conditions.
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Moving From Clinic to Home: What the Future Holds for Ophthalmic Telemedicine.
Holekamp, NM
American journal of ophthalmology. 2018;:xxviii-xxxv
Abstract
PURPOSE To describe the expanding role of telemedicine in healthcare, the key criteria required for a successful device and program implementation, and the current and future role of home monitoring in ophthalmology. DESIGN Expert perspective. METHODS Analysis with real-world interpretation of home monitoring technologies, including current adoption barriers and expanded future demands based on demographic and market forces. RESULTS Remote patient monitoring represents a paradigm shift in the way physicians care for patients. Success depends on meeting several criteria, among which are a recognized value proposition to the physician, robust device performance validation, ease of use for the patient, reliability of connectivity, safe and secure data transmission, and economic feasibility. Ophthalmic diseases, such as age-related macular degeneration, glaucoma, and diabetic retinopathy, are ideal candidates for home monitoring practice integration. Established home monitoring technology is already facilitating early detection and improved visual outcomes for patients with age-related macular degeneration. Future innovation currently underway or on the horizon will continue to evolve and expand the footprint of telemedicine within ophthalmology. CONCLUSION Home monitoring has the potential to enhance the patient-physician relationship and to positively impact visual acuity outcomes in ophthalmic diseases. Advances in technology, demographic shifts, market changes, and patient demand for personalized medicine will require physicians to embrace technology in new and diverse ways, perhaps facilitating widespread adoption of home monitoring technology platforms.
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Deep learning in ophthalmology: a review.
Grewal, PS, Oloumi, F, Rubin, U, Tennant, MTS
Canadian journal of ophthalmology. Journal canadien d'ophtalmologie. 2018;(4):309-313
Abstract
Deep learning is an emerging technology with numerous potential applications in Ophthalmology. Deep learning tools have been applied to different diagnostic modalities including digital photographs, optical coherence tomography, and visual fields. These tools have demonstrated utility in assessment of various disease processes including cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy. Deep learning techniques are evolving rapidly, and will become more integrated into ophthalmic care. This article reviews the current evidence for deep learning in ophthalmology, and discusses future applications, as well as potential drawbacks.
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CHECKPOINT INHIBITOR IMMUNE THERAPY: Systemic Indications and Ophthalmic Side Effects.
Dalvin, LA, Shields, CL, Orloff, M, Sato, T, Shields, JA
Retina (Philadelphia, Pa.). 2018;(6):1063-1078
Abstract
PURPOSE To review immune checkpoint inhibitor indications and ophthalmic side effects. METHODS A literature review was performed using a PubMed search for publications between 1990 and 2017. RESULTS Immune checkpoint inhibitors are designed to treat system malignancies by targeting one of three ligands, leading to T-cell activation for attack against malignant cells. These ligands (and targeted drug) include cytotoxic T-lymphocyte antigen-4 (CTLA-4, ipilimumab), programmed death protein 1 (PD-1, pembrolizumab, nivolumab), and programmed death ligand-1 (PD-L1, atezolizumab, avelumab, durvalumab). These medications upregulate the immune system and cause autoimmune-like side effects. Ophthalmic side effects most frequently manifest as uveitis (1%) and dry eye (1-24%). Other side effects include myasthenia gravis (n = 19 reports), inflammatory orbitopathy (n = 11), keratitis (n = 3), cranial nerve palsy (n = 3), optic neuropathy (n = 2), serous retinal detachment (n = 2), extraocular muscle myopathy (n = 1), atypical chorioretinal lesions (n = 1), immune retinopathy (n = 1), and neuroretinitis (n = 1). Most inflammatory side effects are managed with topical or periocular corticosteroids, but advanced cases require systemic corticosteroids and cessation of checkpoint inhibitor therapy. CONCLUSION Checkpoint inhibitors enhance the immune system by releasing inhibition on T cells, with risk of autoimmune-like side effects. Ophthalmologists should include immune-related adverse events in their differential when examining cancer patients with new ocular symptoms.
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The role of vitamin D in the pathogenesis of ocular diseases.
Skowron, K, Pawlicka, I, Gil, K
Folia medica Cracoviensia. 2018;(2):103-118
Abstract
The prevalence of vitamin D deficiency in the American and European population is estimated to be extremely high. Although fewer people today su er from serious health problems related to calcium and phosphate metabolism resulting from vitamin D deficiency, there are more and more studies suggesting that calcitriol may play an important role in the pathogenesis of other diseases in virtually every body system. A growing body of research shows that through its ubiquitously expressed receptor, calcitriol displays potent anti-angiogenic an anti-inflammatory activity. This review summarizes recent discoveries regarding these non-classical effects of vitamin D and their clinical implications. Data collection focused on the prevention and treatment of ocular diseases as well as on the underlying mechanisms.
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Delivery of therapeutics for deep-seated ocular conditions - status quo.
Nguyen, H, Eng, S, Ngo, T, Dass, CR
The Journal of pharmacy and pharmacology. 2018;(8):994-1001
Abstract
OBJECTIVES There is a need for research into designing effective pharmaceutical systems for delivering therapeutic drugs to the posterior of the eye for glaucoma-related pathology, macular degeneration, diabetic retinopathy, macular oedema, retinitis and choroiditis. Conventionally, eye drops have been extensively utilised for topical drug delivery to the anterior segment of the eye, but are less effective for delivery of therapeutics to the back of the eye due to significant barriers hampering drug penetration into the target intraocular tissue. This review explores some of the current and novel delivery systems employed to deliver therapeutics to the back of the eye such as those using liposomes, ocular implants, in situ gels, and nanoparticles, and how they can overcome some of these limitations. KEY FINDINGS Issues such as blinking, precorneal fluid drainage, tear dilution and turnover, conjunctiva and nasal drug absorption, the corneal epithelium, vitreous drug clearance, and the blood-ocular barriers are reviewed and discussed. SUMMARY Further studies are needed to address their shortcomings such as drug compatibility and stability, economic viability and patient compliance.
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Nd:YAG laser vitreolysis versus pars plana vitrectomy for vitreous floaters.
Kokavec, J, Wu, Z, Sherwin, JC, Ang, AJ, Ang, GS
The Cochrane database of systematic reviews. 2017;(6):CD011676
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Abstract
BACKGROUND The vitreous is the clear jelly of the eye and contains fine strands of proteins. Throughout life the composition of this vitreous changes, which causes the protein strands in it to bundle together and scatter light before it reaches the retina. Individuals perceive the shadows cast by these protein bundles as 'floaters'. Some people are so bothered by floaters that treatment is required to control their symptoms. Two major interventions for floaters include Nd:YAG laser vitreolysis and vitrectomy. Nd:YAG laser vitreolysis involves using laser energy to fragment the vitreous opacities via a non-invasive approach. Vitrectomy involves the surgical replacement of the patient's vitreous (including the symptomatic vitreous floaters) with an inert and translucent balanced salt solution, through small openings in the pars plana. OBJECTIVES To compare the effectiveness and safety of Nd:YAG laser vitreolysis to pars plana vitrectomy for symptomatic vitreous floaters. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 17 January 2017), Embase Ovid (1947 to 17 January 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 17 January 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 17 January 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 17 January 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 17 January 2017. We did not use any date or language restrictions in the electronic searches for trials. We also searched conference proceedings to identify additional studies. SELECTION CRITERIA We included only randomised controlled trials (RCTs) that compared Nd:YAG laser vitreolysis to pars plana vitrectomy for treatment of symptomatic floaters. DATA COLLECTION AND ANALYSIS We planned to use methods recommended by Cochrane. The primary outcome we planned to measure was change in vision-related quality of life from baseline to 12 months, as determined by a vision-related quality of life questionnaire. The secondary outcomes we planned to measure were best corrected logMAR or Snellen visual acuity at 12 months for the treated eye(s) and costs. Adverse outcomes we planned to record were the occurrence of sight-threatening complications by 12 months (asymptomatic retinal tears, symptomatic retinal tears, retinal detachment, cataract formation, and endophthalmitis). MAIN RESULTS No studies met the inclusion criteria of this review. AUTHORS' CONCLUSIONS There are currently no RCTs that compare Nd:YAG laser vitreolysis with pars plana vitrectomy for the treatment of symptomatic floaters. Properly designed RCTs are needed to evaluate the treatment outcomes from the interventions described. We recommend future studies randomise participants to either a Nd:YAG laser vitreolysis group or a vitrectomy group, with participants in each group assigned to either receive treatment or a sham intervention. Future studies should follow participants at six months and 12 months after the intervention. Also they should use best corrected visual acuity (BCVA) using an Early Treatment of Diabetic Retinopathy Study (ETDRS) chart read at 4 metres, vision-related quality of life (VRQOL), and adverse outcomes as the outcome measures of the trial.
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Ocular Manifestations of Obstructive Sleep Apnea.
Santos, M, Hofmann, RJ
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2017;(11):1345-1348
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) incurs a host of systemic side effects. The eyes are particularly susceptible to both mechanical and vascular sequelae of the disease. This paper outlines the ocular manifestations of sleep apnea. The authors hope to increase awareness of the ocular complications of this common disorder and increase communication and co-management between eye-care providers and sleep specialists alike. METHODS Data were collected from PubMed and the Brown University Library Collection. RESULTS Twenty-two papers were included in this review to address floppy eyelid syndrome, nonarteritic anterior ischemic optic neuropathy, central serous retinopathy, retinal vein occlusion, and glaucoma. We used three meta-analyses and several cross-sectional cohort and case-control studies that investigate the aforementioned conditions and their associations with OSA. CONCLUSIONS Hypoxia induced by nightly cessation of breathing increases patients' risk of coronary artery disease, heart failure, stroke, and other conditions. As with many maladies detrimental to vascular health, obstructive sleep apnea affects the eye and ocular adnexa. This paper summarizes the current evidence implicating OSA in these ocular maladies and highlights their proposed mechanisms. The authors describe ocular pathology which sleep specialists may encounter. We encourage more aggressive attention to ocular symptoms in patients with sleep apnea to prevent vision-threatening complications. Further research should investigate how sleep apnea treatment affects these ocular findings and identify which sleep apnea patients are most prone to developing ocular pathology.
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Ophthalmic clues to the endocrine disorders.
Liu, Z, Chen, Y, Lin, Z, Shi, X
Journal of endocrinological investigation. 2017;(1):21-25
Abstract
PURPOSE Eye is a vital sense organ and reflects the physical and mental wellbeing of a person. Detailed examination of the eye is an essential part in the clinical evaluation of patients with any systemic disorder. The interaction between ophthalmologists and endocrinologists is often limited to Graves' ophthalmopathy and diabetic retinopathy. However, there are many ophthalmic manifestations, which are characteristically seen in endocrine disorders. In this review, we shall discuss the ocular manifestations of the endocrine syndromes excluding the Graves' ophthalmopathy and diabetic retinopathy. METHODS We performed a PubMed search of articles published in English showing the ophthalmic features in the endocrine disorders. Relevant cited articles were also retrieved. RESULTS Most of the publications included in the review were case reports and review articles. Many endocrine disorders have characteristic manifestations pertaining to the various structures of the eye. The involvement is seen from the external structures of the eye to the inner most layers of the retina. Many ocular-endocrine syndromes also exist with characteristic clues to the clinical diagnosis. CONCLUSION The endocrinologists need to be aware of these ocular signs that help in the early diagnosis of the underlying disorder. A syndromic approach is essential in the diagnosis of endocrinopathy in patients presenting with ophthalmic features.