April 2023

Carlos Neves
Portuguese Retina and Vitreous Group

The first but not the last

I have selected an article that brings news not about Retina but about the universe of scientific publishing: the text is by Holden Thorp, the editor of Science, and in it he discusses the work of Alondra Nelson, a highly decorated sociologist appointed by President Joe Biden as Deputy Director for Science in the Office of Science and Technology Policy (OSTP) in 2021, and who leaves a legacy of science policymaking that encourages equity. In the world of scientific publishing, Nelson will be remembered for a memorandum establishing requirements for public access to research results that have received federal support. The "Nelson memo," as it is commonly referred to, offers different routes to this end: a scientific paper can be published in an open access journal; alternatively, authors can deposit a paper that has been accepted by a journal (but not yet published) in a public repository. Nelson says that making "the knowledge ecosystem more equitable in different ways" requires a multifaceted strategy that considers low- and middle-income countries as well as institutions that work with minorities.

Ricardo Parreira
Portuguese Group of Pediatric Ophthalmology and Strabismus

ERN GENTURIS tumor surveillance guidelines for individuals with neurofibromatosis type 1

In the current NHS context, managing the follow-up timings of our patients, in the balance between what would be ideal and what is possible or reasonable, is a common difficulty in the clinical practice of all Pediatric Ophthalmologists. This article, supported by the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), addresses surveillance strategies for tumors associated with Neurofibromatosis type 1(NF1), namely Optic Fibrosis Glioma and Plexiform Neurofibroma.
I chose this article because, although guidelines on medical care in NF1 already exist, they lack integration with everyday clinical practice. In this article, surveillance guidelines are provided in the European context, with timings considered appropriate for the care needed by these patients, trying to avoid unnecessary consultations or diagnostic tests. In addition, the role of optical coherence tomography (OCT) and whole-body MRI in this context is discussed.

AAPOS uniform guidelines for instrument-based pediatric vision screen validation 2021

Instrument Referral Criteria for PlusoptiX, SPOT and 2WIN Targeting 2021 AAPOS Guidelines

In 2013, the American Association of Pediatric Strabismus and Ophthalmology (AAPOS) updated the 2003 guidelines for screening and referral of preschool children assessed with instruments capable of detecting potentially amblyogenic risk factors. However, in this publication, the prevalence of refractive errors in the population was not considered, resulting in over-referral of astigmatism and hyperopia and under-referral of anisometropia. New guidelines were published by AAPOS in 2022, taking into account these factors, with the expectation of reducing the number of false positives referred. In another article, the same author compared the results of three different photorefraction instruments with ophthalmic cycloplegic refraction, in order to adapt the reference cut-offs of each instrument to the guidelines revised by the AAPOS. In our current national context, in which the Childhood Eye Health Screening Program (SVI) has an increasing adherence by the population, the analysis and reflection on these articles is relevant, given the discrepancy between the ability to screen and the ability to ophthalmologically evaluate the referred children.

Nuno Alves
Portuguese Group of Ocular Surface, Cornea and Contactology

João Feijão
Portuguese Group of Implanto-Refractive Surgery

Topical Losartan and Corticosteroid Additively Inhibit Corneal Stromal Myofibroblast Generation and Scarring Fibrosis After Alkali Burn Injury

This preclinical study reveals the efficacy of Losartan, used in a topical formulation, in reducing corneal opacity. Apparently, this systemic antihypertensive drug when used on the ocular surface, acts by reducing type IV collagen production via TGF-B modulation, decreasing myofibroblast activation and thus corneal fibrotic scar density. In some centers, namely in South America, it is already being applied "off label" in patients with corneal haze after refractive surgery with interesting results. Eventually, this study may have opened a new medical therapeutic line in an area without valid therapeutic alternatives.

Lígia Ribeiro
Portuguese Group of Neurophthalmology

Diagnosis and classification of optic neuritis

The discovery of specific antibodies for some types of optic neuritis, the emergence of optical coherence tomography in its diagnosis and evolution, advances in neuroimaging, new epidemiological data of the different subgroups and the emergence of targeted therapeutic options make a new classification of inflammatory optic neuropathies urgently needed. In this context, the group led by Axel Petzold published a position paper in The Lancet Neurology on diagnostic criteria and classification of optic neuritis. The information gathered by the Delphi method involved 101 specialists from 60 countries, with the participation of 3 Portuguese colleagues. According to the panel, definitive diagnosis of optic neuritis requires clinical manifestations attributable to optic neuropathy together with one or more paraclinical criteria (OCT findings, MRI or biomarkers). In the article a classification scheme based on clinical, serological and anatomical dimensions is proposed and the therapeutic approach is discussed.

You can hear Dr. Petzold discuss the study on The Lancet Neurology's podcast, available on Spotify, Player FM and Apple Podcasts.

GenEye24: Novel rapid screening test for the top-3 Leber's Hereditary Optic Neuropathy pathogenic sequence variants

The research team at the University of Coimbra led by Professor Manuela Grazina has developed a methodology that allows the identification of the three most frequent pathogenic variants (Top3) that represent 95% of the total genetic alterations identified in Leber's Hereditary Optic Neuropathy, within a 24-hour period, with high sensitivity and specificity. This pioneering approach in suspected LHON can expedite diagnostic and therapeutic decisions. The article "GenEye24: Novel Rapid Screening Test for the Top-3 Leber's Hereditary Optic Neuropathy Pathogenic Sequence Variants" was published in the journal Mitochondrion.

Nádia Lopes
Portuguese Orbit and Oculoplastic Group

Role of teprotumumab in the treatment of active moderate-to-severe Graves' orbitopathy

This article, written by endocrinologist Luigi Bartalena, assesses the role of teprotumumab, a monoclonal antibody that inhibits the insulin-like growth factor receptor, in the treatment of moderate to severe forms of thyroid orbitopathy.
Teprotumumab was cleared by the FDA in 2020 for the treatment of Graves' orbitopathy, however its use has not yet been approved in Europe.

Like the e.v. corticosteroids, it was shown to be highly effective in treating inflammatory changes. However, teprotumumab was more effective in resolving diploplia and exophthalmos, with a marked reduction in exophthalmos values, comparable to those obtained after orbital decompression.

Despite the encouraging results, before preempting corticosteroids as first-line therapy, some aspects related to teprotumumab should be addressed, namely its high cost and evaluation of the long-term safety profile.

João Breda
Portuguese Research Group

Visual Field Endpoints for Neuroprotective Trials: A Case for AI-Driven Patient Enrichment

Artificial intelligence (AI) promises to revolutionize the way we deal with patients, from diagnosis to treatment. But it actually promises much more... In the field of research it can have a tremendous impact. A recent publication shows how AI can make research more cost-effective-which could open up new horizons in studying complex areas that require long follow-ups, such as glaucoma and, within this, neuroprotection.

This study, which represented a joint effort of two research groups (David Crabb and Aaron Lee), showed how AI can identify higher risk patients who are more likely to suffer early progression, thus being able to conduct clinical trials with fewer patients and shorter follow-up times.

They give as an example that for a 3-year study, with 80% power to detect a difference and an effect size of 30%, the AI model was able to reduce the sample of patients from 1656 to 636. If there was no selection by the AI model, to get the same result with 636 patients, 5 years of clinical trial would be needed.

As we all know, a single day of clinical testing incurs enormous costs. This new route may make it possible to conduct therapeutic (and other) trials that would otherwise be abandoned.

Vanda Nogueira
Portuguese Group for Ocular Inflammation

Vaccine-Associated Uveitis after COVID-19 Vaccination: Vaccine Adverse Event Reporting System Database Analysis

Following the start of the global vaccination program for COVID-19 in 2021, ocular adverse effects have begun to be described, with numerous publications appearing in recent months and reflecting the identified ophthalmic adverse effects. The benefits of vaccination are far greater than the associated risk of ocular inflammation. But it is imperative that the ophthalmologist knows its potential adverse effects and anticipates a correct approach.

With the approval of vaccines in an emergency context, the Centers for Disease Control and Prevention has extended the period of the Vaccine Adverse Event Reporting System, a passive surveillance platform that allows for the timely identification and alerting of potential unanticipated effects.

Based on these records between 2020 and 2022, Singh et al. studied the risk of uveitis associated with the SARS-Cov-2 vaccine. During this period, a total of 1,250310 adverse effects were reported (corresponding to 0.06% of all vaccine doses), including 1094 uveitis, the latter being more frequent in women. They were observed in subjects with a mean age of 46.24 ± 16.93 and were most frequent after the first dose of vaccine, with about 50% of cases diagnosed in the first week and 75% in the first month. Few patients had a history of prior COVID-19 (0.8%), uveitis (9.6%), or autoimmune systemic disease (1.2%). Anterior uveitis was the most common (44.9%), but other types of ocular inflammation are described both in this platform and in the literature, such as cases of episcleritis, anterior scleritis, keratic transplant rejection, pars planitis pan-uveitis, acute macular neuro-retinopathy, evanescent white spot syndrome, multifocal choroiditis, reactivation of inflammatory retinal neovascularization, reactivation of Vogt-Koyanagi-Harada disease, and retinal vasculitis. Other post-vaccine ophthalmologic manifestations are also described, such as acute macular neuro-retinopathy, acute paracentral middle maculopathy, retinal venous or arterial occlusion, optic neuritis, acute non-arteritic ischemic optic neuropathy,craneal pair palsies, central venous sinus thrombosis, and Graves' disease-related orbitopathy. There are many more reviews published in the last year, which I invite you to read.

Teresa Gomes
Portuguese Glaucoma Group

Santen Receives FDA Approval for Omlonti for Primary Open-Angle Glaucoma

The importance of this news is that Omlonti is the first of a new class of ocular hypotensive drugs, selective agonists of the PGE2 EP2 receptors. Its hypotensive effect results from the enhancement of aqueous humor drainage through the conventional and uveoscleral routes.

Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension

The LIGHT (Laser in Glaucoma and Ocular Hypertension) study is now extended to a 6-year period, reinforcing the good results obtained at 3 years. The comparison, made with hypotensive eye drops, shows the superiority of SLT in terms of disease progression, the need for cataract surgery, the need for glaucoma surgery and the Qol of patients. SLT is thus reaffirmed as an alternative to ocular hypotensive eye drops as the first therapeutic approach for open angle glaucoma.

Artificial Intelligence to Aid Glaucoma Diagnosis and Monitoring: State of the Art and New Directions

This review article clarifies some concepts and terms used in the AI-related literature and further discusses the application of this new technology to glaucoma. This is a topic that will inevitably be present in glaucoma forums, so it is important to be informed in order to understand benefits, limitations and potential drawbacks in its use.

Guilherme Castela
Portuguese Group for Oncologic Pathology and Ocular Genetics

Cemiplimab for Orbital Squamous Cell Carcinoma in 11 Cases

This article tells us about the treatment of advanced Orbital Squamous Cell Carcinoma with Cemiplimab. We know that squamous cell carcinoma or squamous cell carcinoma is the second most common type of skin cancer, after basal cell carcinoma, and usually develops in sun-exposed areas. Orbital involvement is usually secondary to local extension of tumors of the skin, conjunctiva, paranasal sinuses, and oral cavity. Cemiplimab is a fully human monoclonal antibody of human immunoglobulin G4(IgG4) that binds to programmed cell death receptor -1 (PD-1) and blocks its interaction with its ligands PD-L1 and PD-L2. It is approved by the FDA and the European Commission for the treatment of adults with metastatic or locally advanced cutaneous squamous cell carcinoma who are not candidates for curative surgery or radiotherapy.In this publication the authors treated 11 patients with orbital squamous cell carcinoma with cemiplimab showing an efficacy rate in 82% of cases (9 patients), thus avoiding exenteration.

This publication demonstrates the growing importance of immunomodulation in cancer treatment.

Ana Almeida
Portuguese Group of Ergoftalmology

Improving Visual Comfort during Computer Gaming with Preservative-Free Hyaluronic Acid Artificial Tears Added to Ergophthalmological Measures

This prospective study by Vaz et al. evaluated the use of hyaluronic acid artificial tears on the signs and symptoms of digital asthenopia in participants of a video game convention. Participants were randomized into a control group (n=26) who adopted ergo-ophthalmic measures and a group who in addition to ergo-ophthalmic measures instilled a 1 drop of 0.15% hyaluronic acid four times daily (n=30). Participants were evaluated at the beginning of the convention and after 3 consecutive days of playing video games intensively. After the 3 days, the control group showed a significant increase in signs and symptoms of dry eye as well as eye fatigue. This study concludes that the addition of artificial tears has a protective effect against ocular asthenopia associated with prolonged monitor use.

Relationship between vision impairment and employment

This paper published by Chai et al. in the British Journal of Ophthalmology looked at the relationship between visual impairment and unemployment. Using the Singapore Epidemiology Eye Disease Study cohort which included 7608 individuals with a mean follow-up of 6.2 years and a prevalence of 20.2% (n=1536) of visual loss this study concludes that even mild visual loss is associated with unemployment. The authors propose that future studies should investigate how to improve employability in people with visual loss.

What do eye care workers do when their patients go blind

Despite medical advances, there is a percentage of individuals who progress irreversibly to blindness. After visual loss health care professionals are supposed to refer these patients to rehabilitation services; however, this does not always happen.
In this article by Adio et al. published in the British Journal of Visual Impairment, they conducted a survey of visual health professionals to understand the causes of under-referral. In cases of childhood blindness, 87.4% of the professionals send patients to differentiated schools, although only 25% ensure that the children actually attend these schools. 39% admitted that knowing the patient personally increased the likelihood of referral.
One of the authors' conclusions is that while there are many campaigns about blindness, very few focus on what happens after visual loss.

Diogo Hipólito
SPO Youth

I would like to take this item to highlight a series of columns written by invitation by Dr. Robert Osher in the Journal of Cataract and Refractive Surgery from September 2022 through the most recent issue of the journal, aimed specifically at young ophthalmologists.

Throughout the various editions, Dr. Osher describes various maneuvers to be used in cataract surgery that may help prevent the occurrence of complications in particular situations, always accompanied by excellent iconography.

Little pearls for routine cases

In the first edition he gives us some basic notes for standard cases concerning the creation of the initial paracentesis, injection of visco-surgical device, correct size and execution of the capsulorhexis, removal of the cortex and hydration of the main incision.

Pearls for the young cataract surgeon: Creating space in the shallow or crowded anterior chamber by intermittent globe compression

In the next issue, he presents us with a non-invasive technique to obtain space in an eye with a narrow anterior chamber by compressing the eyeball using a strabismus hook, followed by an issue where he tells us about his technique for posterior polar cataracts called Escape Route, which makes it safer to mobilize the adherent epinucleus without increasing the risk of posterior capsule rupture.

Pearls for the young cataract surgeon: the brunescent cataract

Pearls for the young cataract surgeon: the white cataract

The next two editions are dedicated to two challenging situations: white cataracts and brunescent cataracts. During the text you will be introduced step by step to the precautions to be taken and useful strategies for the surgery to be performed successfully and safely.

Pearls for the young cataract surgeon: the pupil of concern

He then talks about small pupils, namely about the different pharmacological and mechanical strategies to overcome this difficulty and ensure greater surgical comfort.

Indispensable things

Finally, in the last issue he describes some peculiarities about his usual surgical practice, drawing attention to the importance during the learning period for imaging and video systems for later visualization and gesture optimization.