Alfonso Anton

Objectives: This study aimed to evaluate the diagnostic performance of peripapillary retinal nerve fiber layer (RNFL) thickness measurements corrected by artificial intelligence (AI) compared to original uncorrected values for glaucoma detection in highly myopic patients. Methods: This cross-sectional diagnostic accuracy study included 57 eyes from highly myopic patients (31 with glaucoma, 26 without glaucoma). Peripapillary RNFL parameters were obtained using Spectralis optical coherence tomography (OCT). A deep learning algorithm (MGU-Net) was employed to automatically segment retinal layers and compensate for scan tilt in elongated eyes, producing AI-corrected measurements. RNFL thickness values were extracted for six sectoral parameters (ST, SN, N, IN, T, IT) and global. Diagnostic performance was assessed using area under the ROC curve (AUC) and compared between corrected and uncorrected values. Multivariable logistic regression models were also developed using stepwise selection. Results: AI-corrected values were significantly lower than original measurements in all sectors (p < 0.001), with mean differences ranging from 15 to 35 µm. In glaucomatous eyes, significant thinning was observed in the global (p = 0.049) and inferior nasal (IN) sector (p = 0.037) among corrected values. The highest AUCs were found in IN (0.69), IT (0.67), and global (0.66) for corrected values, and in IT (0.63), T (0.59), and global (0.63) for uncorrected data. A model combining ST, T, and IT AI-corrected values achieved an AUC of 0.79. Conclusions: AI-corrected RNFL thickness measurements improve consistency and enhance diagnostic performance in highly myopic glaucoma patients. Correction algorithms may reduce false positives and help reveal glaucomatous damage otherwise obscured by myopic anatomical changes.

Purpose: To evaluate refractive outcomes and associated factors in patients undergoing combined filtering glaucoma surgery (trabeculectomy or non-penetrating deep sclerectomy (NPDS)) and cataract extraction with toric intraocular lens implantation. Design: Prospective consecutive case series. Methods: This prospective case series included 43 eyes of 32 patients with preoperative corneal astigmatism ≥ 0.75 diopters (D) and moderate-to-severe open-angle glaucoma. Patients underwent trabeculectomy or NPDS and cataract surgery with toric intraocular lens (IOL) implantation. Main outcomes included refractive astigmatism (vector and refractive analysis), spherical equivalent (SE), mean absolute error (MAE), prediction error, intraocular pressure (IOP), and the influence of surgical technique and IOL characteristics. Results: Mean refractive astigmatism decreased from 2.29 ± 1.02 D to 0.57 ± 0.44 D at 6 months ( p < 0.001). Mean SE improved from −1.38 ± 3.52 D to 0.06 ± 0.45 D. The MAE was 0.59 ± 0.40 D. No significant correlation was found between refractive results and surgical technique or IOL type. Complete IOP control without medication was achieved in 88.3% of eyes. Visual acuity improved in 97.6% of patients Conclusions: Combined glaucoma filtering surgery with toric IOL implantation yields effective astigmatism correction and favorable refractive outcomes without compromising IOP control. This approach is a valuable option for patients with moderate-to-severe glaucoma and preexisting corneal astigmatism.

Introduction: To compare the efficacy and safety of trabeculectomy with a collagen matrix implant (Ologen^®) versus trabeculectomy with mitomycin C (MMC) versus trabeculectomy with both Ologen^® and MMC (OLO + MMC). Methods: This non-randomized study included 119 eyes of 101 patients with uncontrolled open-angle glaucoma who underwent trabeculectomy, either alone or combined with phacoemulsification. The data were initially recorded following a standard surgical protocol, using an electronic database with structured fields. The patients were divided into three groups: 44 received trabeculectomy with adjunctive MMC (MMC group), 34 received surgery with Ologen^® (OLO group), and 41 received surgery with both Ologen^® and MMC (OLO + MMC group). The main outcome measures were the change in intraocular pressure (IOP), change in number of medications needed, complete success rate (defined as IOP ≤ 20 mmHg and at least 20% IOP reduction without hypotensive medications), rate of complications, and rate of postoperative interventions. The follow-up period was 36 months. Results: IOPs significantly decreased (p = 0.01) in all groups across all study visits, decreasing from 19.8 ± 4.6 mmHg to 12.7 ± 4.2 mmHg in the MMC group, from 20.5 ± 4.7 mmHg to 13.9 ± 3.5 mmHg in the OLO group, and from 23.5 ± 6.1 mmHg to 13.1 ± 3.5 mmHg in the OLO + MMC group. After correcting for the baseline IOP, only the first two postoperative visits (first week and first month) showed a significantly greater IOP reduction in the OLO + MMC group. The number of hypotensive medications was significantly reduced from 3.1 ± 0.6 to 0.56 ± 1.1 in the MMC group, from 2.9 ± 0.4 to 0.83 ± 1.1 in the OLO group, and from 3.0 ± 0.6 to 0.45 ± 0.95 in OLO + MMC group, with no statistically significant differences among the groups (p = 0.57). The complete success rates were 63.6% in the MMC group, 67.6% in the OLO group, and 80.5% in the OLO +MMC group, with no statistically significant differences between the groups (p = 0.21). Suture release was significantly more frequent in the MMC group (86.1%) than in the OLO group (62.1%) and in the OLO + MMC group (45.9%; p = 0.02). Bleb needling, with (33.3%; p = 0.005) or without (66.7%; p = 0.0001) 5-fluorouracil injection (5-FU), was significantly more common in the MMC group. The highest complete success rate (61%) was observed in the OLO + MMC group. Conclusions: The use of Ologen^® and mitomycin C provided similar surgical IOP reduction in glaucoma surgery compared with either MMC or Ologen^® alone, but significantly reduced the need for postoperative interventions.

Purpose: To compare the efficacy and safety of trabeculectomy with a collagen matrix implant (Ologen®) versus trabeculectomy with mitomycin C (MMC) versus trabeculectomy with both Ologen® and MMC (OLO+MMC). Methods: This non-randomized study included 119 eyes of 101 patients with uncontrolled open-angle glaucoma who underwent trabeculectomy, either alone or combined with phacoemulsification. Data were initially registered following a standard surgical protocol and using an electronic database with structured fields. Patients were divided into three groups: 44 received trabeculectomy with adjunctive MMC (MMC group), 34 with Ologen® (OLO group), and 41 with both Ologen® and MMC (OLO+MMC group). The main outcome measures were the change in intraocular pressure (IOP), change in number of medications needed, complete success rate (defined as IOP≤20 mmHg and at least 20% IOP reduction without hypotensive medications), rate of complications, and rate of postoperative interventions. The follow-up period was 36 months. Results: IOP significantly decreased (p=0,01) in all groups across all study visits, decreasing from 19.8 ± 4.6 mmHg to 12.7 ± 4.2 mmHg in the MMC group, from 20.5 ± 4.7 mmHg to 13.9 ± 3.5 mmHg in the OLO group, and from 23.5 ± 6.1 mmHg to 13.1 ± 3.5 mmHg in the OLO+MMC group. After correcting for baseline IOP, only the first two postoperative visits (first week and first month) showed significantly greater IOP reduction in the OLO+MMC group. The number of hypotensive medications was significantly reduced from 3.1±0.6 to 0.56±1.1 in the MMC group, from 2.9±0.4 to 0.83±1.1 in the OLO group, and from 3.0±0.6 to 0.45±0.95 in OLO + MMC group, with no statistically significant differences among the groups (p=0,57). Complete success rates were 63,6% in the MMC group, 67,6% in the OLO group, and 80,5% in the OLO +MMC group, with no statistically significant differences among the groups (p=0,21). Suture release was significantly more frequent in the MMC group (86,1%) than in the OLO group (62,1%) and in the OLO + MMC group (45,9%; p=0,02). Bleb needling, with (33.3%; p=0.005) or without (66.7%; p=0.0001) 5-Fluorouracil injection (5-FU), was significantly more common in the MMC group. The highest complete-success rate (61%) was offered by the OLO+MMC group. Conclusion: The use of Ologen® and Mitomycin C provided similar surgical IOP reduction in glaucoma surgery compared with MMC or Ologen® either alone but significantly reduced the need for postoperative interventions.

Low-income countries carry approximately 90% of the global burden of visual impairment, and up to 80% of this could be prevented or cured. However, there are only a few studies on the prevalence of retinal disease in these countries. Easier access to retinal information would allow differential diagnosis and promote strategies to improve eye health, which are currently scarce. This pilot study aims to evaluate the functionality and usability of a tele-retinography system for the detection of retinal pathology, based on a low-cost portable retinal scanner, manufactured with 3D printing and controlled by a mobile phone with an application designed ad hoc. The study was conducted at the Manhiça Rural Hospital in Mozambique. General practitioners, with no specific knowledge of ophthalmology or previous use of retinography, performed digital retinographies on 104 hospitalized patients. The retinographies were acquired in video format, uploaded to a web platform, and reviewed centrally by two ophthalmologists, analyzing the image quality and the presence of retinal lesions. In our sample there was a high proportion of exudates and hemorrhages—8% and 4%, respectively. In addition, the presence of lesions was studied in patients with known underlying risk factors for retinal disease, such as HIV, diabetes, and/or hypertension. Our tele-retinography system based on a smartphone coupled with a simple and low-cost 3D printed device is easy to use by healthcare personnel without specialized ophthalmological knowledge and could be applied for the screening and initial diagnosis of retinal pathology.

(1) Background: After filtering surgery, bleb morphology is an indicator of the factors that may determine the final intraocular pressure (IOP). The present study aimed to evaluate and compare filtering bleb characteristics after combined cataract and glaucoma surgery. (2) Methods: We conducted a prospective multi-center randomized trial. Eyes with glaucoma and cataract were randomly assigned to either phacoemulsification and filtration surgery with an EX-PRESS implant (Alcon) or non-penetrating deep sclerectomy (NPDS) with an ESNOPER implant (AJL). The bleb characteristics were assessed with the Moorfields bleb grading system at months 1 and 12 of follow-up, and the relationship with IOP was analyzed. (3) Results: There were significant changes in bleb appearance between the assessments at month 1 and month 12. The changes in bleb appearance were more evident in the EX-PRESS group. The central area in the EX-PRESS group decreased from 2.9 at month 1 to 2.4 at month 12 (p = 0.014). Bleb height in the EX-PRESS group decreased from 2.3 at month 1 to 1.8 at month 12 (p = 0.034). The vascularity of the central area in the NPDS group decreased from 1.8 at month 1 to 1.3 at month 12 (p = 0.02). The maximal bleb area was inversely related (r = −0.39; p = 0.03) to the IOP in the NPDS group at month 1. Vascularity in the central area was directly related (r = 0.39; p = 0.01) to a higher IOP in the EX-PRESS group at month 1. Vascularity in the central area (r = 0.56; p < 0.001) and maximal area (r = 0.37; p = 0.012) at month 1 was directly related to a higher IOP in the EX-PRESS group at month 12. (4) Conclusions: More intense vascularity at month 1 was related to a higher final IOP in the EX-PRESS group. Larger blebs were associated with a lower IOP in the NPDS group.

Précis: The manuscript evaluates cost-effectiveness of glaucoma screening with imaging devices and telemedicine based on a screening campaign performed in Spain. The screening strategy implemented in our analysis was cost-effective compared with opportunistic case finding. Introduction: Open angle glaucoma is an asymptomatic ocular disease that represents one of the first causes of blindness. Diagnosis is currently made by opportunistic case finding, usually by community optometrists or general ophthalmologists. The aim of this study was to assess the cost-effectiveness of a screening strategy based on optical coherence tomography and fundus photographs in glaucoma detection. Materials and Methods: A cost-effectiveness analysis was carried out to compare 2 alternative strategies: opportunistic finding versus screening. A Markov tree model was carried out with 10 health states according to disease progression. Quality-adjusted life years (QALYs) were used as a measure of effectiveness. We included short-term and long-term direct health costs and a discount rate of 3%. We performed a probabilistic sensitivity analysis and several 1-way sensitivity analyses. Results: The cohort in the screening program entailed an increase in 0.097 QALYs and additional costs of €1187 versus opportunistic finding, with an incremental cost-effectiveness ratio of about €12.214/QALY. The 1-way sensitivity analysis showed that inputs related to age and screening program (cost and detection rate) were those most strongly influencing the results of the analysis. Probabilistic sensitivity analyses showed that the model was robust to significant changes in the main variables of the analysis. Conclusions: The screening strategy implemented in our analysis was cost-effective compared with opportunistic finding in patients with glaucoma in this Spanish setting.

The role of nutraceuticals in the treatment of glaucoma remains controversial. The aim of this study was to evaluate the effect of citicoline, vitamin C, and docosahexaenoic acid (DHA) in patients with glaucoma. Methods: This was a prospective, randomized study. Patients with glaucoma were randomized to one of four groups and treated for 3 months with vitamin C, DHA, citicoline, or a combination of DHA and citicoline. We conducted a complete ophthalmic examination and visual fields each month and calculated the slopes of field indices. Changes in visual field indices (VFIs) and their slopes were assessed in each group and compared. Results: Seventy-three persons were included in the study. Mean defect (MD) significantly improved (p = 0.001) from −9.52 ± 4.36 to −7.85 ± 4.36 dB during the study period in persons taking DHA + citicoline. Similarly, the mean VFI significantly improved (p = 0.001) in this group. The only treatment group showing a statistically significant improvement (p = 0.006) in the MD (from −0.1041 ± 0.2471 to 0.1383 ± 0.2544 dB/month) and VFI slope was the group treated with DHA+citicoline. Conclusions: The combination of oral treatment with DHA + citicoline significantly improved VF indices and their slopes in patients with glaucoma after 3 months of treatment.

Purpose: The aim of this study was to evaluate the diagnostic accuracy of optical coherence tomography (OCT) and retinography in the detection of glaucoma through a telemedicine program. Methods: A population-based sample of 4113 persons was randomly selected. The screening examination included a fundus photograph and OCT images. Images were evaluated on a deferred basis. All participants were then invited to a complete glaucoma examination, including gonioscopy, visual field, and dilated fundus examination. The detection rate, sensitivity, specificity, and positive and negative predictive values were calculated. Results: We screened 1006 persons. Of these, 201 (19.9%) were classified as glaucoma suspects; 20.4% were identified only by retinographs, 11.9% only by OCT images, and 46.3% by both. On ophthalmic examination at the hospital (n = 481), confirmed glaucoma was found in 58 (12.1%), probable glaucoma in 76 (15.8%), and ocular hypertension in 10 (2.1%), and no evidence of glaucoma was found in 337 (70.0%). The detection rate for confirmed or probable glaucoma was 9.2%. Sensitivity ranged from 69.4% to 86.2% and specificity from 82.1% to 97.4%, depending on the definition applied. Conclusions: The combination of OCT images and fundus photographs yielded a detection rate of 9.2% in a population-based screening program with moderate sensitivity, high specificity, and predictive values of 84–96%.