Investigation of the Impact of Keratoconus on the Posterior Segment of the Eye
The study investigated keratoconus using Pentacam and Corvis to classify the condition and optical coherence tomography (OCT) and OCT angiography to assess retinal vessel density. It included three groups: a keratoconus group (180 eyes), a small forme fruste keratoconus group, and a control group with normal corneas. Results revealed statistically significant differences in retinal vessel density, particularly between the keratoconus and control groups, with higher vessel density observed in the macular region in keratoconus patients.
There is ongoing debate regarding the causes of keratoconus, with some attributing it to eye rubbing while others suggest a genetic basis. Though traditionally defined as non-inflammatory, studies over the past two decades proposed that keratoconus may have an inflammatory component. Its association with atopic conditions supports this. The diagnostic approach is evolving, with new methods like Corvis, OCT, ultrasonography, and Brillouin microscopy enabling earlier detection by evaluating corneal biomechanics. These advancements may improve screening, particularly for pediatric keratoconus, which often presents at advanced stages despite available treatments like cross-linking. The potential for inflammation affecting retinal vessels in keratoconus patients raises questions, but further study is needed. OCT continues to be a revolutionary tool, shedding light on ocular and neurological diseases.
Easy Ways to Make Cataract Surgery more Sustainable
A study on enhancing the sustainability of cataract surgery. Operating rooms (OR), including those used for cataract procedures, are major contributors to carbon emissions, with the healthcare sector responsible for 4-10% of global emissions. Their study explored minor changes in the OR, such as removing green tubing and chair arm covers, switching to electronic prescriptions, and reducing chloramphenicol usage. These adjustments resulted in significant reductions in both carbon emissions and costs. A checklist was developed for sustainable practices across different phases of surgery—preoperative, intraoperative, and postoperative—demonstrating that small changes can significantly impact sustainability and cost savings.
The discussion on sustainability highlighted the importance of small, practical steps in reducing carbon emissions in healthcare settings. The presented poster was likely favored for demonstrating actionable changes in a hospital setting, showing that even minor adjustments can make a difference. For those interested, the European Society of Cataract and Refractive Surgeons (ESCRS) Sidics calculator is a tool that helps assess the carbon footprint of cataract surgery packs, comparing emissions to benchmarks and guiding decisions on potential reductions. Additionally, introducing a new, compact pack with smaller drapes—suggested by several European centers—illustrates a practical approach to reducing waste. Platforms like EyeSustain offer valuable resources and exchanges for improving sustainability practices. Everyone is encouraged to consider these measures in their settings.
The discussion on sustainability in cataract surgery underscores the need to balance environmental concerns with the quality of patient care. Some hospitals are exploring eliminating side port knives in favor of using single-use knives for all procedures. While the approach aims to reduce waste and carbon emissions, it raises concerns about potentially compromising the quality of surgical outcomes. The ESCRS benchmark set includes a paracentesis knife, and it is important to maintain high surgical standards even as we strive for greater sustainability. The shift towards single-use items reflects a broader trend driven by sterility and infection control concerns. Surgeons are often hesitant to embrace reusable tools due to the responsibility for maintaining sterility and the potential for being held accountable if something goes wrong. The move towards single-use items was initially motivated by a focus on reducing infection risk, but it has created challenges in achieving sustainability goals. Addressing these challenges requires gathering evidence supporting reusable tools' safety and effectiveness. The evidence would help overcome resistance from OR staff and support integrating more sustainable practices. Additionally, the impact of surgical complications, which often lead to increased use of materials and more frequent hospital visits, must be considered in the overall carbon footprint. By reducing complications, we can mitigate some of the negative environmental impacts of cataract surgery. The need for evidence-based decisions is critical in the face of commercial pressures from the industry, which often promotes disposables as a convenient solution. These marketing practices have led to increased costs and environmental impacts despite similar levels of efficacy. The scientific community must advocate for more economical studies and evidence-based practices to ensure that sustainability efforts are effective and practical. Finally, collaboration with the industry is crucial for advancing sustainability in healthcare. Commercial interests drive the industry's focus on disposables, but a shift towards more sustainable options requires cooperation and reevaluating current practices. The ongoing dialogue will be essential in finding solutions that balance environmental responsibility with high-quality patient care.
A Violinist's Duet with Bilateral Toric Intraocular Lenses
A 55-year-old myopic female underwent immediate sequential bilateral cataract surgery with toric intraocular lenses (IOLs), initially experiencing clear vision postoperatively. However, by the third day, her vision deteriorated significantly. Examination revealed that both toric lenses had rotated clockwise from their intended axis, resulting in residual astigmatism. The patient, an avid violinist, had been engaged in high-tempo playing involving vigorous head movements and rapid vibrato. The authors suspect these intense head movements may have contributed to the IOL rotation, as such rotations are typically rare with the lens type. After repositioning the lenses, the patient was advised to avoid playing the violin to prevent further rotation. The case highlights the importance of considering patient-specific activities and movements in postoperative care. It raises the question of whether traditional practices adequately ensure IOL stability. It highlights the potential impact of vigorous physical activities on IOL placement and suggests that personalized postoperative strategies may be required for patients with unique lifestyle factors.
Considering the implications of this case, it is crucial to evaluate whether our postoperative guidelines should be adjusted for patients engaged in specific activities, such as violinists. Many of us do not differentiate between spherical and toric lenses in terms of postoperative care beyond the basic recommendations like avoiding swimming and contact sports. However, the case highlights the need to address individual patient activities that might impact lens stability. One approach might be to advise patients to adopt more restrictive behaviors immediately after surgery. For instance, urging them to keep their head movements minimal and to avoid strenuous activities in the initial days could be beneficial. The issue becomes especially relevant for patients engaged in high-movement activities or professional sports, such as the violinist. Additionally, there's a discussion about whether a more vertical sleeping position on the first night could help, as some surgeons suggest it could minimize lens rotation. Various approaches to handling postoperative care reflect personal experience and clinical practice differences. Some surgeons suggest that in cases where lens rotation is easy to correct during surgery, additional postoperative caution might not be necessary. In contrast, in more challenging cases, extra care might be warranted. The variability in practices is highlighted by subjective approaches, such as recommending a nap post-surgery to minimize movement. Ultimately, the case encourages us to think more critically about personalized postoperative instructions based on the individual's lifestyle and surgical circumstances. It also points to the need for further study and evidence to guide these practices, ensuring effective patient care and lens stability.
Chord μ and Chord alpha - Two Rather Robust Parameters
The next study by Asal and colleagues from Heidelberg focused on anterior segment imaging, specifically examining chord μ and chord alpha. These parameters were explored to determine if they could predict issues associated with multifocal lenses, such as reduced contrast sensitivity and photic phenomena like glare and halos. Chord μ and Chord α are measurements taken with the Pentacam. Chord μ is the distance between the pupil's center and the light reflection's vertex, while chord alpha measures the distance from the cornea's center to the light reflection's vertex. In their study involving over 1,000 cases, Asal and colleagues found that chord μ and Chord α showed minimal variation between the right and left eyes and no significant differences between genders. However, differences were noted between short and long eyes and between myopic and hyperopic eyes. Additionally, chord μ was observed to increase with age. The key question is whether these parameters offer practical value in predicting multifocal lens performance. Although chord μ and Chord α provide interesting data, their clinical application for forecasting lens-related issues remains uncertain. Previous studies have suggested that chord μ might indicate lens centration, but it is known to change postoperatively due to pupil size adjustments, which could affect its reliability. Chord α has been explored for its potential correlation with the capsular bag, but more evidence is needed. Advanced imaging techniques like Three Dimensional Optical Coherence Tomography (OCT 3D) may offer better insights into lens centration and postoperative changes. Profilometry, which depends on pupil size and centration, could also provide useful information. While chord μ and Chord α contribute valuable data, their direct application in predicting multifocal lens outcomes requires further investigation to establish their clinical relevance.
Even if the differences in chord μ and Chord α were significant, their practical utility remains limited. Once the lens is in place, its positioning is largely fixed, and we cannot alter it further. It reflects the inherent imperfection in the human visual system, which is often decentered relative to geometric objects. However, imperfection can be a factor in binocular vision and depth perception, which we have adapted to over time. The observed differences between myopic and hyperopic eyes align with expectations due to their differing distances, but age introduces another layer of complexity. As people age, the pupil size decreases, and its ability to contract diminishes, which could affect measurements like chord mu. It is a significant factor, considering all patients will eventually age, potentially altering their ocular measurements. While these measurements can provide insight into clinical practice, they don't offer direct solutions. For example, while chord μ might be used to assess if an eye is an outlier, it doesn't change the fundamental approach to lens positioning or power calculations. In cases where measurements are significantly off, they may influence decisions or highlight potential issues, but they do not change the fact that lens positioning remains largely uncontrollable. The importance of chord μ and Chord α lies more in understanding their limitations than applying them directly in lens positioning. For instance, while these parameters might affect IOL power calculations due to variations in actual length, their role is more about identifying potential issues rather than offering actionable solutions. For those involved in IOL placement, focusing on centering the lens as best as possible and understanding the limitations of these measurements is crucial. However, the inherent variability in the human eye means that while measurements like chord μ and Chord α can offer useful data, they are not definitive in controlling or correcting lens position once the surgery is completed.
Exploring the Potential of ChatGPT-4 in Predicting Refractive Surgery Categorizations: A Comparative-Study
The study explores the application of ChatGPT-4, a generative Artificial intelligence (AI) model, in predicting patient categorization for refractive surgeries such as Laser-Assisted In Situ Keratomileusis (LASIK), Photorefractive Keratectomy ( PRK), and IOL. The aim is to assess whether ChatGPT can effectively categorize patients based on a range of clinical and imaging data compared to traditional clinician assessments. Data collection involved patients during their first-time visits from June to August 2021, focusing on those without keratectasia on follow-up. Key variables included patient demographics (e.g., sex, spherical and cylindrical equivalents, axis), visual acuity, and various imaging metrics (e.g., Best Corrected Visual Acuity (BCVA), thinnest pachymetry, Anterior Chamber Depth (ACD), Belin/Ambrosio Display (BAD), and index of surface irregularity (I-s)). The data assessed patients who underwent LASIK PRK or were deemed unsuitable for surgery due to ectasia risk or other reasons. Based on the data, the study employed ChatGPT-4 to categorize patients, showing varying degrees of agreement with clinician categorizations. For a two-category comparison (surgery vs. no surgery), ChatGPT demonstrated higher accuracy and recall, with a Cohen's kappa of 0.610, indicating "substantial agreement" with the clinician. In contrast, for a six-category comparison, accuracy decreased, with a Cohen's kappa of 0.399 reflecting "fair agreement." The findings suggest that while ChatGPT-4 shows promise in categorizing patients for refractive surgeries, variability in AI prompts and the involvement of only one clinician highlight areas for further study. The 2024 re-test using ChatGPT-4 showed a decrease in agreement, with Cohen's kappa dropping to 0.21 for six categories and 0.52 for two categories. It suggests that while ChatGPT-4's capabilities are evolving, more data and refinement are needed for reliable patient categorization. Overall, the study underscores the potential of generative AI like ChatGPT for supporting clinical decision-making but also points out the limitations and variability that need to be addressed for more accurate and consistent application in patient assessments.
The conversation surrounding AI's role in medical decision-making, particularly with tools like ChatGPT, raises important considerations about the future of patient care and clinical practices. While AI technology, including ChatGPT-4, offers significant advancements, such as enhanced predictive capabilities and data analysis, some inherent challenges and concerns must be addressed. One concern is the potential for AI to become a "black box," where the decision-making process is not fully transparent or understandable. In clinical settings, protocols and guidelines are established to ensure consistency and adherence to best practices. However, the algorithms driving AI tools can sometimes obscure the rationale behind their recommendations, making it difficult to grasp how decisions are made fully. Additionally, there's a risk of bias in AI systems. If an AI tool is trained on data that includes inherent biases, these biases could be reflected in its recommendations, potentially affecting patient care and outcomes. The issue underscores the need for careful oversight and validation of AI tools to ensure they provide fair and accurate assessments. From a practical perspective, there are scenarios where AI might suggest treatment options based on available data. Still, these recommendations must be evaluated based on individual patient needs and clinical judgment. For instance, if a patient insists on a particular procedure based on online information, the clinician must assess whether the AI's recommendation aligns with the patient's specific medical conditions and preferences. Moreover, integrating AI into medical practice raises questions about the training and expertise of future medical professionals. There is concern that reliance on AI might diminish the emphasis on traditional learning methods and critical thinking skills. It's essential to balance AI's assistance with a strong foundation in medical knowledge and patient interaction. The accuracy of AI tools like ChatGPT has improved over time, with ChatGPT-4 showing an accuracy of around 85% in certain scenarios, comparable to human experts. However, AI should complement rather than replace human expertise. Maintaining transparency about how AI systems operate and ensuring their use adheres to the scientific method and ethical standards is crucial. Ultimately, AI has the potential to significantly enhance medical practice by providing valuable insights and data analysis. However, it is important to continuously evaluate its role, address biases, and ensure that human oversight remains a central component of patient care. The goal should be to leverage AI to support and augment clinical decision-making while upholding the principles of transparency, equity, and professional expertise.
The Heritage Lecture marks the 75th anniversary of the first IOL implantation, a pivotal moment in ophthalmology. The milestone will be celebrated in London on November 29. Richard Packard's presentation highlights the contributions of Charlie Kelman, who revolutionized cataract surgery with his development of phacoemulsification. Initially an aspiring musician, Kelman was directed by his father to pursue medicine, where he pioneered small incision cataract surgery. Supported by a Hartford Foundation grant and with the assistance of Otto Richter and Cheryl Jalbert, Kelman advanced surgical techniques, leading to significant improvements in cataract surgery.
42nd Congress of the European Society of Cataract and Refractive Surgeons, 6 – 10 September 2024, Fira de Barcelona, Spain.
