Enrico Bernardi

Purpose: To develop and evaluate the accuracy and safety of a customized, domain-restricted chatbot providing postoperative patient education after vitreoretinal surgery. Methods: We evaluated a domain-restricted GPT-4 chatbot accessed through the OpenAI API and implemented with retrieval-augmented generation, a curated vitreoretinal postoperative knowledge base, a persistent system prompt, and rule-based safeguards. Nineteen frequently asked postoperative questions were each submitted in three independent fresh sessions, generating 57 responses. Each response was rated by one of three retinal specialists as accurate and sufficient, partially accurate and sufficient, or inaccurate, and screened for hallucination. Results: Across 57 reviewer ratings, 53 (93.0%; 95% CI 83.0–98.1) were rated accurate and sufficient and 4 (7.0%; 1.9–17.0) partially accurate and sufficient; none was inaccurate. Sixteen of 19 questions (84.2%; 60.4–96.6) received unanimous accurate-and-sufficient ratings. Disagreement was confined to three activity-related questions: lifting, exercise, and driving. Hallucinations occurred in 3 of 57 ratings (5.3%; 1.1–14.6), all in activity advice and each flagged by a single reviewer; none arose in red-flag symptom responses. Inter-rater agreement was high (pairwise agreement 89.5%; Gwet’s AC1 0.88). Conclusion: A customized, domain-restricted chatbot is a feasible and safe approach to postoperative vitreoretinal patient education, with the only residual inconsistencies arising in areas where clinical practice itself varies between surgeons.

Objective: To examine the prognostic significance of intraretinal hyperreflective foci (HRF) and subretinal drusenoid deposits (SDD) as predictors of atrophy presence and progression to exudative macular neovascularisation (eMNV) in the unaffected second eye of participants with eMNV in the first eye. Methods: Post hoc prognostic analysis on iAMD eyes from the prospective EDNA cohort. SD-OCT scans of 459 study eyes were graded for presence of HRF, SDD, and their characteristics, including location within retina (inner, outer, or both), proximity to irregular elevation of RPE (adjacent, remote or both), and SDD load (mild or moderate to severe). The cohort was subdivided in four follow up groups, iAMD without focal regions of atrophy (FoA), persistent or new onset FoA, eMNV alone and eMNV with FoA. Results: Of the 459 included eyes, 234 (51.0%) had HRF and 273 (60.0%) had SDD at baseline. Persistent or new onset FoA was seen in 83, 66 progressed to eMNV alone and 38 to eMNV with FoA, and 272 had no worsening of iAMD status. Presence of HRF and especially a higher SDD load were associated with a significantly faster progression to exudation. A higher SDD load doubled the hazard of progression to any eMNV compared to eyes with a mild load or without SDD. This hazard was highest in eyes with the presence of both HRF and SDD. HRF were associated with a lower BCVA. Conclusions: HRF and SDD are consistently observed in high risk AMD eyes and characterising their distribution and load might allow differentiation of their contributions to risk of progression to late stage features of atrophy and exudation.

Purpose: To evaluate the diagnostic performance of final-year ophthalmology residents in classifying keratoconus using standard Scheimpflug corneal tomography and to compare their accuracy to that of experienced corneal specialists. Design: Prospective, investigator-initiated, multicenter observational study. Methods: Five final-year residents assessed 1,239 anonymized Pentacam HR (Oculus GmbH, Germany) quad-map outputs, categorized as normal, suspect keratoconus, or keratoconus, previously obtained from 620 pediatric patients in a prior population-based imaging study. Two corneal experts independently established the reference standard. Residents rated their diagnostic confidence using Likert scales. Agreement was quantified using Cohen's kappa (κ) and Fleiss's κ. Results: Resident-to-expert agreement ranged from Cohen's κ = 0.031 to 0.324 (slight to fair). Overall inter-rater reliability across all raters was slight, Fleiss's κ = 0.088. Four residents rated their diagnostic skill as neutral; one rated it as poor. Self-assessed competence relative to peers was rated as neutral by three residents and good by two. Conclusions: Final-year ophthalmology residents showed limited agreement with expert graders when interpreting Scheimpflug images. The alignment between self-assessed confidence and measured diagnostic performance highlights a potential educational gap in image-based diagnosis of ectatic corneal disease. These findings support the need for competency-based curricular enhancements, including image interpretation benchmarks, expert-guided calibration sessions, and simulation-based learning modules, aiming to improve diagnostic accuracy and support earlier detection of keratoconus. Further multicenter studies are needed to validate these results and guide national and international training strategies.

Background/Objectives: Cystoid macular edema (CMO) is a common complication that follows cataract surgery, presenting management challenges due to the lack of standardized treatment guidelines and the potential for spontaneous resolution. This study aimed to evaluate various treatment modalities for post-operative CMO, including topical non-steroidal anti-inflammatory drugs (NSAIDs), periocular steroids, and intravitreal injections. Methods: A systematic review of the literature was conducted to assess the efficacy of different treatment approaches for post-operative CMO. Studies evaluating topical NSAIDs, periocular steroids, intravitreal triamcinolone acetonide (TCA), dexamethasone implants (Ozurdex), and intravitreal bevacizumab were included. The main outcomes assessed included improvements in vision, resolution of CMO, recurrence rates, and safety profile. Results: Topical NSAIDs, particularly ketorolac and diclofenac, showed effectiveness in acute CMO, while their efficacy in chronic cases was variable. Periocular steroids, including retrobulbar TCA and sub-Tenon injections, demonstrated significant improvements in vision and the resolution of CMO, especially in cases resistant to topical therapy. Intravitreal TCA and dexamethasone implants exhibited variable effects on CMO resolution and recurrence rates, with some studies reporting sustained improvements over 12 months. The role of intravitreal bevacizumab as initial therapy remains unclear, although it may be considered in cases unresponsive to steroids. Conclusions: Topical NSAIDs, often combined with periocular steroids, serve as first-line therapy, with periocular steroids offering additional efficacy in resistant cases. Further research is needed to establish optimal treatment algorithms and improve outcomes for patients with post-operative CMO

Purpose: To review the incidence, risk factors, and treatments for cystoid macular edema (CME) following rhegmatogenous retinal detachment (RRD) repair surgery. Methods: A comprehensive literature search was conducted across multiple databases. Relevant studies published within the last 20 years were selected and reviewed. Results: The incidence of CME following RRD repair ranges from 6% to 36%, with higher rates associated with silicone oil tamponade. Key risk factors include recurrent RRD, pre-existing proliferative vitreoretinopathy, older age, and post-RRD cataract surgery. Treatment options primarily focus on anti-inflammatory approaches, with topical NSAIDs and corticosteroids as first-line treatments. For persistent cases, intravitreal corticosteroid injections, particularly dexamethasone implants, have shown potential. Conclusion: CME remains a significant complication following RRD repair, impacting visual recovery. While various treatment options exist, management of persistent CME remains challenging. Better understanding of the underlying mechanisms of CME is required to develop more effective treatment strategies, particularly for cases resistant to current therapies. Plain Language Summary: Cystoid macular edema is a common complication following rhegmatogenous retinal detachment repair, affecting visual recovery. Its incidence varies widely, influenced by surgical approach and patient factors. Treatment primarily involves anti-inflammatory medications, with intravitreal corticosteroids showing promise for persistent cases. Further research is needed to improve management of this challenging complication.

Purpose: To compare the anatomical and functional outcomes of pars plana vitrectomy (PPV) alone versus PPV with the addition of a scleral buckle in treating inferior rhegmatogenous retinal detachments (RRDs). Methods: Comparative, retrospective cohort study including patients who were diagnosed with primary inferior RRD, defined as RRD with one or more retinal tears located between 4 and 8 hours, and divided into two treatment groups. Group 1 patients were treated with PPV and gas tamponade alone, whereas group 2 patients were treated with PPV, gas tamponade and the addition of an encirclement band. Demographic and clinical features were collected, and surgical outcomes of both groups were analysed. A univariable logistic regression model evaluated the factors influencing surgical success. Results: A total of 161 eyes were included in the study. The average age at diagnosis was 64.1 years. There was a male predominance (66.5%), and most patients had macula-off detachments (54%). Group 1 included 75 eyes (43.1%), whereas group 2 included 86 eyes (56.9%). Baseline best-corrected visual acuity was 1.00 logMAR, improving to 0.62 logMAR at the last visit (p=0.003). No significant difference in primary success rate was observed between the two groups (86.0% with encirclement band vs 80.0% without; p=0.3). The mean follow-up period was 29 weeks (SD 39). Conclusions: PPV alone may be as effective as PPV with an encirclement band when treating inferior RRDs. The choice of tamponade does not appear to significantly influence anatomical success, and short-acting gas can be considered sufficient for favourable outcomes.

Objectives: The aim of this review paper is to summarise surgical options available for repairing iris defects at the iris–lens plane, focusing on suturing techniques, iridodialysis repair, and prosthetic iris devices. Methods: A thorough literature search was conducted using multiple databases, including Medline, PubMed, Web of Science Core Collection, and the Cochrane Library, from inception to February 2024. Relevant studies were screened based on predefined criteria, and primary references cited in selected articles were also reviewed. Results: Various surgical techniques were identified for iris defect repair. Suturing methods such as interrupted full-thickness sutures and the McCannel technique offer solutions for smaller defects, while iridodialysis repair techniques address detachment of the iris from the ciliary body. Prosthetic iris devices, including iris–lens diaphragm devices, endocapsular capsular tension ring-based devices, and customizable artificial iris implants, provide options for larger defects, each with its own advantages and limitations. Conclusions: Successful iris reconstruction requires a personalised approach considering factors like defect size, ocular comorbidities, and patient preference. Surgeons must possess a thorough understanding of available techniques and prosthetic devices to achieve optimal outcomes in terms of both visual function and, nonetheless, cosmetic appearance.

Purpose. The aim of this study was to compare effectiveness and safety of MicroPulse transscleral laser therapy (MP-TLT) using the original MicroPulse P3® device and continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) using the G-Probe® device in glaucoma. Methods. Spherical equivalent, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and number of topical or oral ophthalmic pressure-reducing medications were registered at every time point, up to the last follow-up at 12 months. A complete slit-lamp examination was conducted to record the following complications: corneal edema, persistent ocular hypotony (IOP ≤5 mmHg) on two consecutive follow-up visits, choroidal detachment, phthisis bulbi, sympathetic ophthalmia, cystoid macular edema, or other abnormal ocular findings. Success was defined as IOP between 6 and 21 mmHg and >20% reduction in IOP with or without antiglaucoma medications. Results. 47 eyes underwent MP-TLT and 150 CW-TSCPC. At 12 months, success was achieved in 88.6% in the CW-TSCPC group and 87.5% in the MP-TLT group ( = 0.883). In the CW-TSCPC group, eyes achieved a 42.4% IOP reduction (from 28.3 ± 12.3 mmHg to 15.3 ± 6.0 mmHg) and a 31.1% reduction (from 22.0 ± 7.2 mmHg to 15.7 ± 4.8 mmHg) in the MP-TLT group. Visual acuity remained primarily unaltered in both groups. Conclusion. MP-TLT was as effective in lowering IOP as CW-TSCPC and achieved comparable success. Additionally, MP-TLT demonstrated consistent and effective outcomes at every time point. The improved safety profile of MP-TLT allows the therapeutic spectrum to be broadened, granting ophthalmologists’ treatment of glaucoma in earlier stages of glaucoma than those typically treated with CW-TSCPC, i.e., early to moderate and to patients with good central-vision.