The Asia-Pacific Journal of Ophthalmology

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Articles appearing in this section have been peer-reviewed and accepted for publication and posted online before formal publication. Articles appearing here may contain statements, opinions, and information that have errors in facts, figures, or interpretation. Accordingly, the editors and authors and their respective employees are not responsible or liable for the use of any such inaccurate or misleading data, opinion or information contained the articles in this section.

Original Study - Clinical

Intra-Arterial Chemotherapy for Retinoblastoma: 8-Year Experience from a Tertiary Referral Institute in Thailand Rojanaporn, Duangnate; Chanthanaphak, Ekachat; Boonyaopas, Rawi; Sujirakul, Tharikarn ; Hongeng, Suradej; Ayudhaya, Sirintara Singhara Na
Purpose: To study the safety and efficacy of intra-arterial chemotherapy (IAC) as a treatment for intraocular retinoblastoma in Thailand.
Design: Retrospective, interventional case series.
Methods: In this study, IAC was performed as primary or secondary treatment for patients with intraocular retinoblastoma using melphalan with or without additional topotecan or carboplatin. Survival rate, globe salvage rate, and treatment complications were recorded and analyzed.
Results: Of 27 eyes of 26 patients with retinoblastoma, 7 (26%) had IAC as primary treatment and 20 (74%) had IAC as secondary treatment. The eyes were classified by International Classification of Retinoblastoma (ICRB) as group B (n = 3, 11%), group C (n = 1, 4%), group D (n = 12, 44%), and group E (n = 11, 41%). Catheterization was successful in 75 (94%) of 80 sessions. The median number of IAC sessions was 3 (range, 1–7). At a mean follow-up of 32 months (range, 3–95 months), the overall globe salvage rate was 52%, with 100% in groups B and C, 75% in group D, and 9% in group E. Complications of IAC included occlusive vasculopathy (n = 4, 15%), vitreous hemorrhage (n = 3, 11%), retinal artery precipitation (n = 2, 7%), strabismus (n = 2, 7%), and transient ischemic attack (n = 1, 4%). The overall survival rate was 96% (n = 25).
Conclusion: Our experience suggests that IAC is a safe and effective treatment for patients with ICRB group B, C, D, and some group E retinoblastoma. Careful patient selection and experienced surgeons are critical for achieving the best treatment outcome.
The Relationship Between Optic Disc Parameters and Female Reproductive Factors in Young Women Lee, Samantha S.Y.; Yazar, Seyhan; Pasquale, Louis R.; Sanfilippo, Paul G.; Hewitt, Alex W.; Hickey, Martha; Skinner, Rachel; Mackey, David A.
Purpose: It has been suggested that female sex steroids have neuroprotective properties that may reduce risk of glaucoma in premenopausal women. In this study, we explored the associations of optic disc measures with female reproductive factors in a population of young women. Design: Cohort study.
Methods: Young women (n = 494; age range, 18–22 years) were recruited as part of the Western Australian Pregnancy Cohort (Raine) Study. Information on age at menarche, parity, and use of hormonal contraceptives were obtained from questionnaires. Participants underwent an eye examination, including spectral-domain optical coherence tomography imaging, to obtain optic disc parameters.
Results: Women who had given birth at least once (parous women;n = 10) had larger vertical neuroretinal rim widths (P < 0.001) than nulliparous women (n = 484) after correcting for use of hormonal contraceptives, intraocular pressure, refractive error, and family history of glaucoma. Furthermore, vertical and horizontal cup-to-disc ratios, which are inherently related to neuroretinal rim width, were found to be smaller among parous women compared with nulliparous women (both P < 0.001). Age at menarche and use of hormonal contraceptives were not significantly associated with any optic disc parameters.
Conclusions: We found limited evidence that female reproductive factors were related with optic disc parameters during young adulthood. The association between parity and optic disc parameter, though significant, should be further investigated given the small number of parous women in the current sample. Future follow-ups of this cohort will allow us to explore for any associations of these factors with optic disc parameters and glaucoma risk at an older age.
Clinical Course and Treatment Response of Neuromyelitis Optica Spectrum Disease: An 8-Year Experience Lin, Chao-Wen; Lin, I-Hung; Chen, Ta-Ching; Jou, Jieh-Ren; Woung, Lin-Chung
Purpose: To report the clinical course and treatment response in a cohort of neuromyelitis optica spectrum disorder (NMOSD) patients from a single referral center.

Design: Case series.

Methods: Ninety-six NMOSD patients who received treatment and follow-up checks at National Taiwan University Hospital for at least 2 years between 2008 and 2016 were recruited. Detailed characteristics of clinical course including acute episodes, maintenance therapies, and visual outcome were collected. Patients were examined every 6 months and during each episode of relapse. The study was approved by the institutional review board and informed consent was obtained.


Results: Among all patients, 68 (70.8%) had optic neuritis. Optic neuritis was the initial presentation of NMOSD in 44 patients. Among patients with optic neuritis, 32.4% had recurrent optic neuritis within 1 year from the first episode. Compared with the group without optic neuritis, the group with optic neuritis had a younger age of presentation (34.4 ± 15.9 versus 42.4 ± 14.7 years, P = 0.02) and a higher 1-year recurrence rate (64.7% versus 17.9%, P < 0.001). Among the patients with optic neuritis, 51.5% of patients had a final visual acuity of worse than 20/200. Multiple regression analysis showed that the presence of aquaporin-4-IgG antibodies and poor initial visual acuity were risk factors of worse visual outcome.

Conclusions: In this study, patients with optic neuritis were younger and had a higher 1-year recurrence rate. Despite using steroid therapy during the acute phase and immunosuppressive agents as long-term treatment, visual prognosis was poor. Aquaporin-4-IgG antibodies and initial visual acuity were associated with final visual outcome.

Review Article

Artificial Intelligence and Optical Coherence Tomography Imaging Kapoor, Rahul; Whigham, Benjamin T.; Al-Aswad, Lama A.
This review article aimed to highlight the application and use of artificial intelligence (AI) in optical coherence tomography (OCT) imaging in ophthalmology. Artificial intelligence programs seek to simulate intelligent human behavior in computers. With an abundance of patient data, especially with the advent and growing use of imaging modalities such as OCT, AI programs provide us with the unique opportunity to analyze this plethora of information and assist in making clinical decisions in the field of ophthalmology. Groups around the world have developed and evaluated AI programs that gather data from diagnostic modalities, such as OCT, that assist in the diagnosis and management of ophthalmological diseases with a high accuracy. Artificial intelligence programs using OCT have the potential to play a significant role in the diagnosis and management of ophthalmological disease in the near future. Incorporation of AI in medicine, however, is not without its pitfalls. Some limitations of AI in ophthalmology are also discussed in this review. These include the deskilling of physicians due to increase in reliance on automation, inability of AI programs to take a holistic approach to clinical encounters with patients, requirement of pre-existing strong datasets to train AI programs, and the inability of AI programs to incorporate the ambiguity and variability that is intrinsic to the nature of clinical medicine.
Optical Coherence Tomography Angiography and Glaucoma: A Brief Review Moghimi, Sasan; Hou, Huiyuan; Rao, Harsha L.; Weinreb, Robert N.
Optical coherence tomography angiography (OCTA) is a new modality in ocular imaging which provides non-invasive assessment and measurement of the vascular structures in the retina and optic nerve head. This technique provides useful information in glaucoma, such as quantitative assessment of vessel density. Vessel density measurement can be affected by various subject-related, eye-related, and disease-related factors. Overall, OCTA has good repeatability and reproducibility, and can differentiate glaucoma eyes from normal eyes. It can also help detect early glaucoma, reach a floor effect at a more advanced disease stage than optical coherence tomography (OCT), and adds information about glaucoma patients at risk of progression. Although it has higher variability than OCT, it also promises to be useful for monitoring glaucoma by detecting progression throughout the glaucoma continuum.
Advances in Corneal Imaging: Current Applications and Beyond Shih, Kendrick Co; Tse, Ryan Hin-Kai; Lau, Yumi Tsz-Ying; Chan, Tommy Chung-Yan
Recent advances in corneal imaging have allowed for more objective diagnosis and disease monitoring, as well as provided valuable guidance for treatment progress. However, there has been limited literature providing comprehensive insight into advances across different imaging modalities. The aim of this review was to provide a brief summary of significant advances in the field of corneal imaging over the past 5 years. A literature search in PubMed was performed on December 11, 2018, using the following key words in various and/or logic combinations: “cornea”, “development”, “advances”, “topography”, “Scheimpflug tomography”, “ultra-high-speed Scheimpflug”, “Corvis ST”, “densitometry”, “optical coherence tomography”, “UHR-OCT”, and “intraoperative OCT”. The initial search showed a total of 2910 articles. Filters were then applied to select original research studies on humans published in the last 5 years which are available in full text and written in English. A final 55 studies were included for analysis. This review looks into 5 key imaging modalities: topography, tomography, confocal microscopy, densitometry, and angiography. For each imaging modality, the underlying scientific principles and current applications are outlined. Existing limitations and potential future applications for each of them are also discussed in this review. Recent advances in the imaging modalities show immense potential in providing objective, high-resolution, and comprehensive visualization of corneal structures and pathologies. Application to different fields in the future is highly probable but technical, economic, and skill-based limitations must first be overcome. Any attempt to replace traditional imaging techniques with these newer techniques must also be supported with evidence from robust clinical studies.
Imaging of Pathologic Myopia Ohno-Matsui, Kyoko; Fang, Yuxin; Shinohara, Kosei; Takahashi, Hiroyuki; Uramoto, Kengo; Yokoi, Tae
Pathologic myopia (PM) is a major cause of irreversible visual impairment worldwide and especially in East Asian countries. The complications of PM include myopic maculopathy, myopic macular retinoschisis, dome-shaped macula, and myopic optic neuropathy. Posterior staphyloma is an important component of the diagnosis of PM and one of the hallmarks of PM. The photographic classification and grading system for myopic maculopathy has already been determined. Conventionally optical coherence tomography (OCT) was commonly used in PM and enabled investigators to image deeper tissue such as choroid and sclera. Today, the technological advances in OCT imaging including ultra-widefield OCT and 3-dimensional construction of OCT have given clinicians a novel insight on variable morphology in the PM.
New Concepts in Polypoidal Choroidal Vasculopathy Imaging: A Focus on Optical Coherence Tomography and Optical Coherence Tomography Angiography Teo, Kelvin Y.C.; Cheung, Gemmy C.M.
Polypoidal choroidal vasculopathy (PCV) is a variant of neovascular age-related macular degeneration. It is characterized by polypoidal dilatations at the terminus of branching vascular network located beneath the retinal pigment epithelium. These polypoidal lesions are best visualized on indocyanine green angiography. With recent advances in ocular imaging, optical coherence tomography (OCT) and OCT angiography (OCTA) have been increasingly used to aid in the diagnosis and monitoring of treatment responses in PCV. This review provides a summary of the current status of various imaging modalities in PCV, with special focus on OCT and OCTA.
Visual Assessment of Aqueous Humor Outflow Xie, Xiaobin; Akiyama, Goichi; Bogarin, Thania; Saraswathy, Sindhu; Huang, Alex S.
In the past decade, many new pharmacological and surgical treatments have become available to lower intraocular pressure (IOP) for glaucoma. The majority of these options have targeted improving aqueous humor outflow (AHO). At the same time, in addition to new treatments, research advances in AHO assessment have led to the development of new tools to structurally assess AHO pathways and to visualize where aqueous is flowing in the eye. These new imaging modalities have uncovered novel AHO observations that challenge traditional AHO concepts. New behaviors including segmental, pulsatile, and dynamic AHO may have relevance to the disease and the level of therapeutic response for IOP-lowering treatments. By better understanding the regulation of segmental, pulsatile, and dynamic AHO, it may be possible to find new and innovative treatments for glaucoma aiming at these new AHO behaviors.
Advances in Whole-Eye Optical Coherence Tomography Imaging Kuo, Anthony N.; McNabb, Ryan P.; Izatt, Joseph A.
Contemporary anterior segment and retinal optical coherence tomography (OCT) systems only image their particular designated region of the eye and cannot image both areas of the eye at once. This separation is due to the differences in optical system design needed to properly image the front or back of the eye and also due to limitations in the imaging depth of current commercial OCT systems. More recently, research and commercial OCT systems capable of “whole-eye” imaging have been described. These whole-eye OCT systems enable applications such as ocular biometry for cataract surgery, ocular shape analysis for myopia, and others. Further, these whole-eye OCT systems allow us to image the eye as an integrated whole rather than as separate, independent divisions.
How to Add Metacognition to Your Continuing Professional Development: Scoping Review and Recommendations Mack, Heather G.; Spivey, Bruce; Filipe, Helena P.
Participation in continuing professional development (CPD) is part of lifelong learning required by ophthalmologists. Metacognition is a new area of educational research. It is important because metacognitive skills are essential in medical education and likely to improve effectiveness of CPD activities. We systematically searched PubMed using the search terms ‘metacognition’ and ‘CPD’ or ‘continuing medical education (CME)’ and found only 5 articles. These articles were supplemented by a broad-based review of published literature including educational psychology, across the continuum of medical education. We summarize the techniques that may improve metacognition in CPD: awareness of and instruction in metacognition, awareness and mitigation of cognitive errors, appropriate needs analysis, and choosing appropriate activities. Metacognition and learning of new surgical techniques, the role of portfolios, and the role of the educator are described. The evidence is weak however, and it is usually extrapolated to CPD activities from other fields. Ophthalmologists may be able to improve their metacognitive skills in the CPD context, but the evidence supporting this is of low quality.
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