This article was reviewed by Raj K. Maturi, MD

The integrin antagonist, THR-687 (Oxurion), showed promising efficacy as a treatment for 

in a multicenter phase 1 clinical trial, said Raj K. Maturi, MD, at the 2020 American Academy of Ophthalmology virtual annual meeting.

The open-label, nonrandomized, dose-escalating study (NCT03666923) enrolled 12 patients who were followed for 3 months after receiving 1 intravitreal injection of THR-687. 

The study met its primary end point as there were no dose-limiting toxicity events by day 14 post injection. 

Study shows positive results in treatment of DME with faricimab


Results from exploratory efficacy analyses showed that THR-687 had the potential for rapid onset of action and reasonable durability for improving visual acuity.

“Multiple challenges remain in the management of DME with unmet needs to improve treatment outcomes, speed of treatment benefit, and the duration of response,” said Maturi, a clinical associate professor of ophthalmology at Indiana University School of Medicine, and in private practice at Midwest Eye Institute in Indianapolis, Indiana. “Unlike anti-VEGF agents, integrin antagonists have a broader biologic effect because integrins contribute to the activation of multiple growth factor receptors and are involved in multiple processes resulting in pathological angiogenesis and vascular leakage.”

Maturi noted that based on the phase 1 study findings, a multiple dose, 2-part phase 2 study is planned to select the dose level of THR-687 and to compare it with aflibercept (Eylea, Regeneron) for treatment-naive patients with DME.

Patients were eligible for the phase 1 trial if they had center-involved DME with a central subfield thickness (CST) of 320 µm or greater on spectral-domain optical coherence tomography, best corrected visual acuity (BCVA) between 23 and 62 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and a history of and current response to treatment with anti-VEGF or corticosteroid therapy.

DME strategies directed by knowledge of mechanisms


The study included 3 sequential dose groups: 3 patients received THR-687 0.4 mg, 3 were treated with 1.0 mg, and 6 were treated with 2.5 mg. 

The baseline mean BCVA was 56.3 ETDRS letters for the overall cohort and well-balanced between the 3 dose groups. 

The baseline mean CST was 541.8 µm, and lower in the highest-dose group (499 µm) than in the 2 lower-dose groups (557 µm and 612 µm).

The safety analyses showed a total of 9 adverse events among 5 subjects, but there were no dose-limiting toxicities or serious adverse events.

“All treatment-related adverse events were in the study eye; most were likely related to the injection procedure and the others were likely due to underlying disease progression or concomitant diseases,” Maturi said.

Identifying gaps in anti-VEGF treatment among minorities with DME


Three patients, including 1 treated with the 1.0-mg dose of THR-687 and 2 treated with the 2.5- mg dose, required rescue treatment. Per protocol-defined criteria, this was given for BCVA worsening of 10 ETDRS letters or more, or a 50-µm or greater increase in CST as assessed by the study investigator. 

The BCVA and CST data for these patients were censored at the time of rescue injection and carried forward for the efficacy end point analyses.

Results from BCVA testing showed a rapid onset of improvement, with a mean gain of 3.1 ETDRS letters seen in the overall cohort on the day after injection and a gain of 7.2 letters by day 7. 

A mean improvement of 9.2 letters was seen at month 1, which represented the peak gain, and BCVA remained improved from baseline by a mean of 8.3 letters at month 3.

Post hoc analysis: Protocol V provides more practical DME guidance for clinicians


The change in BCVA appeared to be dose-related.

“The most pronounced improvement in BCVA was observed in the highest-dose group that had a mean improvement of 9.8 letters by day 7, 11.2 letters by day 14, and a mean gain of 12.5 letters at month 3,” Maturi reported.

In the overall cohort, the treatment was associated with a marginal beneficial effect on CST at 7 days and at 1 month with an increase thereafter. However, the highest-dose treatment group had a mean CST decrease of 106 µm at day 14 and maintained a decrease of 36.5 µm at month 3.


Maturi received clinical research funding from Oxurion (previously ThromboGenics) as an investigational study site for the phase 1 clinical trial of THR-687 for DME.

Articles

Option has a broader biologic effect for patients.

DME trial results are positive for intravitreal integrin antagonist

This article was reviewed by Thulasiraj Ravilla, MBA; and Angus Turner, MD

Mingguang He, MD, PhD, a professor of ophthalmic epidemiology at the University of Melbourne in Australia, described his work in deploying artificial intelligence (AI) in a telemedicine service to provide clinical care. 

“Ophthalmology is a highly image-driven specialty,” he said, which lends itself to telemedicine and AI platforms.

Establishing the AI platform involved data harvesting of images and labeling diseases and their severity in the images. 

From ETDRS to EviRed: Eyeing a new artificial intelligence-based algorithm


He used about 70,000 images to train the neuron algorithm focusing on

Regarding the DR screening classification, internal data validation indicated that the accuracy of the AI algorithm was good; validation of the accuracy in multiple ethnic groups also was very good.


The team repeated this work for glaucoma classification

 and achieved excellent accuracy, and very good accuracy for AMD.

 of deep-learning technology proved that AI can accurately classify diseases based on similar features used by clinicians. 

They then established websites to which clinicians could upload clinical images with diagnosed diseases to see how well AI did in identifying them.

“Most studies reported robust accuracy of the AI classification. Many require real-world validation,” He explained. “The current project targets 4 major diseases and many are trying to create more algorithms to make the diagnosis more accurate or include more diseases. Another area of interest is making an automated care model. Deploying AI in the real world in medicine is challenging and involves more than the neural network, such as many medicolegal issues and patient and doctor interactions.”


Gavin Tan, MD, associate professor at Duke-NUS Medical School, Singapore National Eye Center, Singapore, created a new model of care that integrates the 3 elements for DR screening.

“In ophthalmology, this has been enabled by our embrace of multimodal digital imaging; that is, fundus and slit-lamp imaging and optical coherence tomography, all of which can be delivered remotely to facilitate decision making,” he said.

Tan and his team combined teleophthalmology, AI, and standard fundus cameras to evolve from the traditional print/slide media to digital media in this patient population. 

As he described, the DR diagnosis does not require additional clinical data, the technology provides robust outcomes and cost-effectiveness, and there was less resistance to change by ophthalmologists. 

In addition, the AI training was easy because of the extensive available clinical data.

5 ways the DRCR Retina Network is reshaping diabetic eye disease

The Singapore Integrated DR Program, the bones of which are image capture sites, transmission to a reading center for grading, and reports sent to primary care physicians, covers 150,000 diabetic patients. 

All the data collected were the basis for the AI program, which was seen to make its decisions based on findings similar to those seen as clinicians, he explained, with accuracy of 93.6%.5

The AI program then was integrated into their clinical screening system. The primary grading system is being replaced with the AI linear system (SELENA). 

The images are still graded by human evaluators for patients who are being referred for care to maintain the highest sensitivity and specificity but concurrently reduce the workload substantially.

In addition to screening, 2-way video consults, 1-way virtual clinics by which physicians can review notes and future management is implemented if needed, and home-monitoring devices used by patients to cut travel time and make appointments as needed.

The value of new diagnostics and personalized medicine

Tan’s group has also established a virtual clinic to monitor stable retinal disease that blossomed as the result of 

. 

Patients are classified as having high-intensity active disease requiring monthly treatment or stable disease, the latter representing from 30% to 50% of the population. 

This allows history taking, visual acuity (VA) measurements, and imaging remotely followed by review by technicians and by physicians for management if needed.

The AI system in many cases can be better than physicians in identifying peripheral pathologies such as proliferative DR. The imaging clinics can be combined with video consultations as Tan did with the glaucoma service at the Singapore National Eye Center.

Looking forward, he and his colleagues are starting trials of patients measuring their own VA using mobile applications. They also have started home-monitoring applications that do not require patients to travel for evaluation.

An application called Alleye (Oculocare Medical Inc.) is a pilot home-monitoring device that lets patients determine whether the VA has deteriorated asymptomatically, facilitating early recognition of recurrent disease. 

Developing retinal technologies strengthen visualization



Alleye was tested in about 700 patients with several diseases. 

Over 6 months, 33 patients had triggers, 7 of which were significant and 5 had disease progression.

“Digital technology can transform eye care. Telehealth and AI are highly connected, synergistic technology platforms. Teleophthalmology is successful in screening for DR. AI in ophthalmology shows good performance for specific tasks. Real-world application requires further development and integration. Mobile devices and home monitoring have long-term potential in future eye care,” he concluded.


Thulasiraj Ravilla, MBA, director of operations for Aravind Eye Care System (AECS) in Madurai, India, described how he and his team used telemedicine to provide eye care to millions of Indian patients. 

“Eye care services tend to be urban-centric; our challenge was to bridge the divide to reach patients everywhere,” he said.

AECS opted to use telemedicine to provide universal primary eye care. Ravilla developed a 4-pronged approach to achieve this: focus on community need, comprehensive and quality eye examinations, closing the care loop to ensure appropriate intervention, and remote management. 

Integrating AI to manage DR in a primary care setting



“We see 3 roles for technology: support the caregiving process, manage all associated processes from finance to human resources, and monitor the entire process,” he said.

AECS first built an electronic medical record (EMR) in the cloud for simultaneous collaboration between ophthalmologists and the remote vision technician in rural vision centers. 

All patient information, including history and investigations, is entered live into the EMR. 

This information, combined with real-time conversation with the technician and patient through telemedicine link, facilitated the diagnosis and generating appropriate prescription for spectacles or medicines.

“This technology supported design, closes the care loop within the local setting, and thus enables better adherence by the patients,” he said. 

The vision centers also use AI in the system; a retinal image is uploaded into the cloud and a reading is generated in seconds, giving the severity of the diabetic retinopathy. This technology, as it evolves, can also be used to monitor chronic disease progression.

Deep learning algorithm proven accurate for AMD classification

Ravilla estimated that the network of 79 vision centers covers 6.9 million people. In addition, AECS also has a mobile screening van with a RetCam Shuttle (Clarity Medical Systems, Inc.) to screen for retinopathy of prematurity; using custom-built software, the images are uploaded to the base hospital for review.

“Technology is emerging as a great enabler and makes it possible for millions of people to get good eye care locally. However, the technology needs to be robust, reliable, simple to learn and use, and inexpensive to make financial sense in rural remote settings, where the scale is low,” he emphasized.


Western Australia: Accessing remote indigenous communities


Western Australia has a sparse population spread over vast distances, with some patients traveling 10 hours to obtain surgical services, said Angus Turner, MD, of the Lions Institute in Perth, Australia. 

He explained and emphasized the challenge accessing these individuals who have as everyone elsewhere but with higher prevalence rates because of the gaps in services.

The traditional service had patients traveling hours to reach a specialist for a diagnosis of a cataract, for example, then returning home and waiting 1 to 2 years for a cataract procedure. 

Teleretinal screening fails to do double duty for detecting glaucoma, cataracts



Eliminating the preoperative and postoperative visits in this scenario was key to patients obtaining the needed services.

Optometry and ophthalmology work hand-in-hand in Western Australia. The optometry service is extensive in the Aboriginal population and visits the primary care settings. 

“This is key to our telehealth service. The optometrists perform the evaluations and provide the intimate knowledge about what I need to do surgically or what is required to manage individual patients,” he said.

Telehealth in Australia has focused on diabetic retinal screening for decades and more recently introduced real-time video consultations. 

A mobile van service provides specialist outreach services, and the examination equipment is carted from place to place to facilitate those services.

The video consultations began in 2011 as a result of the Medicare Initiative, and optometry was included in 2015. The system allows the optometrist at one end to evaluate the patient with the video running and the specialist viewing it at the other end.



The initial barriers to the consultation were not technology and cost, but rather the availability of an on-call specialist, the scheduling of 2 health professionals and the patient in a room at the same time, and the alignment of the EMR and the images, he explained.

presented a complication with travel restrictions imposed. Resident optometrists set up clinics in hospitals and used the dormant equipment. 

Telephone interviews, especially for blind patients, were used more. As a result, consultations during 2020 increased by 47% with telehealth. 


This article was adapted from the telehealth presentations during the eyeRISE 2021 virtual symposium. He has no financial interest in this subject matter.


Ravilla has no financial interest in this subject matter.


Turner has no financial interest in this subject matter.


Tan has no financial interest in this subject matter.

--



1. Li Z, Keel S, Liu C, et al. An automated grading system for detection of vision-threatening referable diabetic retinopathy on the basis of color fundus photographs. 

. 2018;41(12):2509-2516. doi:10.2337/dc18-0147

2. Li Z, He Y, Keel S, Meng W, Chang RT, He M. Efficacy of a deep learning system for detecting glaucomatous optic neuropathy based on color fundus photographs. 

. 2018;125(8): 1199-1206. doi:10.1016/j.ophtha.2018.01.023

3. Keel S, et al. CEO 2019; Development and automation of a deep-learning algorithm for the detection of neovascular AMD from color fundus photographs. 

4. Keel S, Wu J, Lee PY, Scheetz J, He M. Visualizing deep learning models for the detection of referable diabetic retinopathy and glaucoma. 

 2019;137(3):288-292. doi:10.1001/jamaophthalmol.2018.6035

5. Ting DSW, Cheung CYL, Lim G, et al. Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations with diabetes. 

. 2017;318(22):2211-2223. doi:10.1001/jama.2017.18152

Worldwide increase in technologies for ophthalmic use is dramatic.

Telemedicine ushers in new chapter in eye care 

Intravitreal pharmacotherapy has emerged as the most effective means of delivering drugs for retinal diseases. 

From a mere few thousand injections delivered worldwide in the early part of this century, it has become one of the most commonly performed ophthalmology procedures.

Pearls for selecting a syringe for intravitreal injection

However, with an aging population in the western world requiring treatment for 

 and diabetes mellitus with its associated diabetic maculopathy projected to rise in the coming years, delivery of intravitreal injections remains a challenge. 

With a publicly funded health service, as with the United Kingdom National Health Service, resource constraints do not permit clinicians to deliver the injections themselves, as this would lead to a shortfall in clinical and surgical activity.

For example, in the United Kingdom, an approach that has been widely accepted and implemented that allows nurses and other allied health care professionals (AHP), including optometrists and orthoptists, to deliver anti-vascular endothelial growth factor (VEGF).

Initiated in 2009, the safety of this service has been amply demonstrated in many studies worldwide.

 

However, the role of nurses and other AHPs has not yet been expanded to the delivery of steroid implants for patients with macular edema due to diabetic maculopathy, retinal vein occlusion, and uveitis.

Study results link frequent anti-VEGF injections, risk of cognitive impairment


Despite the demonstrated safety, there is still some apprehension about nurse-led delivery of steroid implants, one reason purportedly being the bulkier injection system. 

The dexamethasone intravitreal implant (Ozurdex, Allergan) delivery system uses a larger needle (19 gauge) than the fine-bore needle (30 gauge) used for anti-VEGF. Using this larger needle may lead to a higher rate of complications.

There may also be concerns about a lack of demand. The number of steroid implants being injected is a small fraction of the number of anti-VEGF injections given (1/15) in my unit. 

However, although small, this ratio is significant in terms of logistics in service delivery and is steadily increasing.

Historically, clinicians have been averse to the idea of sharing their work with AHPs. 

In ophthalmology, it was seen as a novelty when nurses started injecting anti-VEGF drugs. 

Probe of IRIS registry: Anti-VEGF injections key treatment for PDR



However, ophthalmic nurses had been doing minor invasive procedures such as meibomian cyst excision or subtenon injections of anesthesia for cataract surgery from the early part of this century.

In addition, AHP and nurses have been delivering complex invasive screening and diagnostic services in gastrointestinal medicine, urology, respiratory, and hematology since the late 1980s. 

Randomized study results have shown comparable success and complication rates between clinicians and nurses.


My impetus for encouraging nurses to deliver a dexamethasone implant arose from the protracted waiting time for patients after making the clinical decision to move forward with the procedure. 

This waiting time sometimes exceeded 30 days. 

Audit analysis of the delay revealed 2 reasons for this: firstly, dexamethasone injections were delivered in the operating theater by doctors, and secondly, the injections were scheduled as the last procedure on the theater list, meaning they were prone to cancellation when an emergency operation was needed.

Investigators examine anti-VEGF medications in cases with ROP

I restructured my setup by moving the dexamethasone injection service from the theater to the cleanroom setting alongside the anti-VEGF service. 

This move was considered the only way to reduce the waiting time for injecting the implant and sustaining the service in the long term.

Two senior nurses, experienced in intravitreal injection, were selected to undergo training for injecting dexamethasone implants. 

After initially practicing using porcine eyes in a wet lab, they were then trained on patients by a retina specialist. 

They were certified to undertake the procedures after undergoing a competency assessment by a second independent physician.

The first significant outcome of this nurse-led service was a halving of the waiting time for patients, from 30 to 15 days. 

The safety of the service delivered was audited after the nurses performed 1000 injections, and there were no visually significant complications such as endophthalmitis, iatrogenic cataract, vitreous hemorrhage, or retinal detachment. 

Tool offers ultra-rapid cooling for intravitreal injections



There was only 1 case of incomplete penetration of the implant, but this resolved on conservative treatment with no sequelae.

I believe the following may be some of the reasons for my low complication rate:

> I recruited nurses who were already experienced in intravitreal injections.

> The nurses’ self-audited personal safety profile and complication rate were very low.

> I have adopted a standard anatomical landmark (4 mm behind the limbus) for injection in patients irrespective of their phakic status.

> The framework of training and supervision is robust, and clinicians closely support the service.

Published safety data about nurse-led injection services have been encouraging, with a very low, acceptable level of complications in a clinical care environment.

DME study documents robust efficacy of intravitreal dexamethasone implant



A patient satisfaction questionnaire conducted 3 months after introducing this service showed overwhelming patient satisfaction, with most expressing a desire for the continuation of the nurse-led service. 

Patients also felt the experience was less stressful in the outpatient cleanroom setting as opposed to an operating theater environment.


It is relatively easy to train experienced nurse practitioners as the principle of injection remains essentially the same for all intravitreal injections. 

The time and resources needed are minimal, and they also reduce costs by allowing the clinicians time for other activities. 

And because intravitreal dexamethasone injection is not an operation, it can be safely performed in a cleanroom as with anti-VEGF injections.

It is worth noting that the Royal College of Ophthalmologists, the professional body for ophthalmologists in the United Kingdom, supports AHPs delivering intravitreal injections within a robust clinical governance framework. 

Considerations when using anti-VEGF for treating AMD


However, the pharmaceutical industry does not advocate injection by nonclinicians in its summary of product characteristics either for anti-VEGF or steroid implants. 

But with more safety data being published and the widespread adoption of nurses and AHPs delivering intravitreal injection of different delivery systems, this will probably change. 


Raman is a consultant ophthalmologist at the Royal Eye Infirmary in Plymouth, United Kingdom. He specializes in medical retina and vitreoretinal surgery. He reports no financial disclosures.


1. Simcock P, Kingett B, Mann N, Reddy V, Park J. A safety audit of the first 10,000 intravitreal ranibizumab injections performed by nurse practitioners. 

 2014;28(10):1161-1164. doi:10.1038/eye.2014.153

2. Bolme S, Morken TS, Follestad T, Sørensen TL, Austeng D.. Task shifting of intraocular injections from physicians to nurses: a randomized single-masked noninferiority study. 

2020;98(1):139-144. doi:10.1111/aos.14187

3. Waterman H, Mayer S, Lavin MJ, Spencer AF, Waterman C. An evaluation of the administration of sub-tenon local anaesthesia by a nurse practitioner. 

. 2002;86(5):524-526. doi:10.1136/bjo.86.5.524

4. Williams J, Russell I, Durai D, et al. Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). 

5. Sherman T, Raman V. Incomplete scleral penetration of dexamethasone (Ozurdex) intravitreal implant. 

. 2018;11(1):e227055. doi:10.1136/bcr-2018-227055

Studies on nurse-led services find a low level of complications among patients.

Should nonclinicians inject dexamethasone implants?

Although SARS-CoV-2 has been detected in tears, it is important to note that there is currently no proof that it affects the ocular surface. 

However, clinics and ophthalmic practices have implemented procedures to ensure they can remain open and operate safely during the 

pandemic, and it is more important than ever for surgeons to protect themselves and their patients.

Ophthalmologists and patients need to follow local rules and regulations wherever their practices or hospitals are located. 

Adjusting ophthalmology practice to a pandemic



Unfortunately, policies can differ between countries and sometimes between states in the same country. 

During the pandemic, a key challenge has been finding ways in which ophthalmologists can implement safe practices.

The pandemic has placed an emotional strain on our patients. They are extremely afraid of contracting COVID-19, which has kept many from entering hospitals where there are potentially other sick individuals and where the virus is concentrated.

In ophthalmology, less than 5% of our cases are urgent, wherein a patient has endured trauma to the eye. 

Most of our patients need to be seen on a regular basis, so this presents a dilemma: 

Is it better to preserve their general eye health, increasing the chances of coming into contact with COVID-19, or to defer checkups and reduce the possibility of exposure?

Managing neovascular retinal disease in COVID-19 era requires careful approach

Unfortunately, many patients have chosen to postpone their visits. Some have been doing so for months and even up to a year now, depending on when the COVID-19 outbreak occurred in their places of residence. 

Additionally, our staff—not only physicians but also technicians, nurses, support staff, and administrators—are at high risk of being exposed to the virus because of the number of individuals they come into contact with daily. 

Although staff may not express their worry outright, they know they are in a difficult position because their chosen profession does not allow them the privilege of working safely from home.

The approach to patients, however, is different. Their greatest need is to receive information in advance and to maneuver quickly and securely through the diagnostic pathways.


When the pandemic started, the first thing we did as a practice was to make special shields to prevent very close contact with patients during an examination. 



Patient perception of COVID-19: Too risky for seamless eye care



Although we and the patients wear protective gear, the patients are not fully covered, especially if they are claustrophobic, and we need to adjust.

In the operating room, patients lie on their backs, and we use a microscope that hovers over them, meaning we are in line with their breath at all times. 

Equally, when we are over the operating field, what comes out of our airways goes down to the patients’ exposed eyes. It is technically impossible to wear a shield when operating a traditional microscope during surgery.

To combat this concern, we use a digital microscope, which offers greater opportunities for protecting patients and surgeons from infection during operations. 

The 3-dimensional heads-up microscope allows more distance from the patient. Moreover, because oculars are not used for 3-D surgery, the protection shield above the 3-D glasses is very easy to adjust. 

The microscope allows the nurse to be on the other side of the room and still view the procedure in real time using 3-D glasses, which provides additional safety and allows social distancing. Although the surgeon, nurse, and assistant need to be in the operating room, they can distance evenly, maintaining safer separation.



Implementing COVID-19 safety protocols, guidelines in practice


It seems that it would be easy for a surgeon to choose not to operate on patients who test positive for COVID-19. 

However, in Bulgaria at least, whether patients should be requested to take a COVID-19 test has been controversial for ethical and legal reasons, and hospitals have varying policies in this country.

Although my hospital does not ask patients to be tested for COVID-19 prior to surgery, we do screen them for fever and flu symptoms as well as taking their temperature. If a patient is displaying symptoms, we ask them to see their general practitioner, who decides whether a COVID-19 test is appropriate.

I experienced the delicacy of treating patients with suspected COVID-19 in a case that presented to me at the beginning of the pandemic. In Bulgaria, we initially had a very small number of cases. As most people experienced, we were not allowed to leave the city or even go outside for walks.



Ophthalmology residents retrained as palliative care extenders

During this time, I received a call from my associate at the hospital. There was a 12-year-old girl traveling from Pleven, the hottest region for COVID-19 in Bulgaria, with a perforated eye. 

The reason for the perforation was unknown and the child was also experiencing fever and cough. At that time, I was most worried that the child was coughing, because in cases of perforation the tissues might prolapse.

The anesthesiologist was not able to give the child general anesthesia because of her temperature and other factors. I agreed to see the child, and when I arrived at the hospital almost everyone was staying about 9 feet away from the family.

It turned out that the child was a contact lens wearer; because of the lockdown, she had been unable to buy contacts. 

As a result, she was wearing old lenses that were 2 weeks overdue for changing. The child had anisometropia with plano refraction on one eye and −7.0 D on the other eye.

From the documentation, I discovered that she had developed bacterial keratitis very quickly and her eye was almost perforated. 



Controlling glaucoma uncertainty as COVID-19 limitations continue

In normal times she would undergo lots of tests but instead of moving her around the hospital for evaluations, I decided to examine her in the operating room and be prepared to take material for microbiological evaluation.

I explained to the patient that she needed to be very cooperative because I could not give her general anesthesia due to her coughing. Fortunately, she calmly agreed, especially when I explained that it would be painless.

 imaging, I managed to evaluate her entire 

 while protecting myself from what I thought was a patient potentially infected with COVID-19. 

I found that she, in fact, did not have any perforation. Instead, she had a zone of thinning surrounded by cornea with massive infiltration.

I performed a noninvasive procedure that is painless to the patient, called PAX crosslinking, which uses UV light to kill microorganisms and makes the cornea stronger. I combined the procedure with transplantation of amniotic membrane as a cover.

A potential new symptom of COVID-19: Eye nodules


The 3-D technology and the OCT control, often called the third hand, allowed me to be very precise as I performed these steps. As a result, the child now sees 20/50 with correction, which is a big accomplishment considering that she was about to lose her eyesight.

To complicate the case further, the child and her parents tested negative for COVID-19. In fact, she had ordinary influenza. However, if I had decided to wait 48 hours for COVID-19 test results before operating, she would have lost her vision, which would have been devastating for a girl of such a young age.

In the age of COVID-19 we must be flexible and consider the circumstances of each case individually.


Even though we are in a pandemic, we should not forget the importance of education in medicine. 

Unfortunately, the first thing that happens during a lockdown in a hospital is that, although the permanent staff stays, all people on educational duties are sent home for distance learning. 



Glaucoma care after COVID-19: The Pan-American view

In the long term, we need to consider that if we postpone education for 6 months and then postpone it for another 6 months, a year will go by very quickly, creating gaps in the system for qualified eye specialists.

Moreover, 3-D microscopy offers a great educational tool because students can stay 10 meters away from patients, wear 3-D glasses and be able to look at a big screen and view the surgery as if they are participating. They see so much more detail than if they were looking over the patient with a conventional microscope.


We do not really know how to react to the stress of a global pandemic, and we have surely made—and will make—a lot of mistakes that will be revealed in time.

 However, we need to focus first on being good doctors, good managers, and good teachers. Regardless of the situation, we should continue to treat and work in teams.



Study: Sore eyes a common symptom in COVID-19 patients

Safety is the priority, of course, and new technology is facilitating novel and sometimes very complicated procedures for disinfection and social distancing. Integration and shared information when using equipment is of great help when reducing patient movement is necessary in the clinical setting. 

The circumstances are not easy, but we will survive this and learn more. I hope we will end up with better solutions for the future that are beneficial for ophthalmic care not only during a pandemic but also when we return to normal life. 


Grupcheva is head of the Department of Ophthalmology and Visual Sciences and vice rector at the Medical University of Varna. She represents Bulgaria and is also currently president elect of the European Board of Ophthalmology. She has no financial disclosures related to the content of this article to report.

New operating procedures ensure eye clinics can operate safely amid virus.

Navigating the COVID-19 pandemic with ophthalmic patients in the hospital setting

This article was reviewed by Kuldev Singh, MD



When performing glaucoma surgeries, considering slightly different twists to the procedure may help avoid potential complications.

Paul Palmberg, MD, PhD, a professor of ophthalmology at Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine in Florida, shared his view of the ocular anatomy, which he said helps him to avoid pitfalls and increase patient comfort.

Exploring the evolution of interventional glaucoma


When considering the conjunctiva, Tenon’s capsule, and the sclera, careful techniques can be performed to avoid limbal leaks and bleeding in the conjunctival flap. 

The ocular tissues are not islands but are attached to each other (ie, the conjunctiva is attached to the limbus at the edge of the cornea, and Tenon’s capsule is attached approximately 1 to 2 mm further to the posterior), he explained, reminding surgeons of the blood supply in the conjunctiva and blood vessels on Tenon’s capsule and the scleral surface.

Bleeding inside Tenon’s capsule in the bleb can be avoided if incisions are made only at the insertions of the conjunctiva and Tenon’s capsule. The best route is to get under Tenon’s capsule and not inside of it.

Palmberg noted that the capsule is thicker at the 10 o’clock to 2 o’clock and 4 o’clock to 8 o’clock positions. 

A menu of glaucoma treatments includes options to fit all scenarios

When starting a surgery, he advised using a lateral incision through the conjunctiva and Tenon’s capsule and everting the tissues so that the tips of the scissors can be put sufficiently far from the limbus; this facilitates getting under both the conjunctiva and Tenon’s capsule and down to the bare sclera to take a bite with a suture. 

As the technique progresses, the surgeon can continue around and evert the conjunctiva and Tenon’s capsule.

“The scissors are passing through the potential space under Tenon’s capsule all the way around,” he said.

A radial incision then can be made at the side and spread back through the intermuscular septum to each side of the superior rectus muscle. 

Sponges soaked with mitomycin C (MMC) can be placed through the openings in the intermuscular septum and along the limbus to widely apply the MMC and facilitate extensive spreading of the drug. 


“Wide application of the MMC under a fornix flap avoids a ‘ring of steel,’ that is, scarring, which can delimit the bleb posteriorly,” Palmberg said.

Surgical decision-making in the era of MIGS

This technique was developed by Sir Peng Khaw, MD, PhD, who saw a marked decrease in bleb problems in pediatric cases from 20% to 0%. He used the fornix flap with wide MMC application instead of a limbus-based flap with local MMC application.

“The limbus-based procedure resulted in a focal, highly elevated, thin, and highly vulnerable bleb,” Palmberg said, adding that his bleb-related complications decreased from approximately 8% to 1% at 5-year follow-up.

Another advantage of the fornix-based procedure involves aqueous drainage through Tenon’s capsule on each side of the superior rectus muscle; because the fluid can drain much more freely through lymphatics in the conjunctiva and Tenon’s capsule further back, a much more comfortable bleb forms. 

In contrast, when a limbus-based flap is created, scars form at the incisions in the conjunctiva and Tenon’s capsule—the so-called ring of steel that blocks posterior drainage.

MIGS, other options offer hope for angle-closure patients


Palmberg uses 10-0 nylon to make a bite immediately peripheral to the cornea, down through the scleral, and across and upward; he also closes each side with a bite in the sclera and up through the conjunctiva (square wave bites). 

He explained that he pulls tightly down on this to impale over the needle, comes back out and takes another bite that is tied down under the conjunctiva and run out to the tip, and then takes a bite at the apex and passes it back underneath, tying a knot that is buried under the flap. He repeats the same process on the other side.

Ophthalmologist details his preferred technique to avoid complications during procedure.

Ophthalmology Times: April 1, 2021

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