The edition · Ophthalmology
Saving the eye in advanced retinoblastoma, and the corneas oncology is quietly damaging
Intra-arterial chemotherapy salvages cT3b and cT3c eyes without costing survival, a HER2 antibody-drug conjugate strips the tear film and the subbasal nerve plexus within six weeks, and eight modern lens formulas are ranked in eyes longer than 32 mm.
The edition in brief
A 1566-eye multicentre cohort of treatment-naive unilateral retinoblastoma found intra-arterial chemotherapy salvaged far more cT3b eyes (HR 3.65, 95% CI 1.91 to 6.98) and cT3c eyes (HR 4.02, 2.79 to 5.80) than intravenous chemotherapy, with overall and metastasis-free survival no different from primary enucleation, and about four in five salvaged cT3b/c eyes retaining at least light perception. cT3d eyes gained nothing and still warrant prompt enucleation. A retrospective case series of eight patients on trastuzumab botidotin describes the ocular cost of HER2-targeted antibody-drug conjugates: symptoms starting about 37 days after the first dose and peaking near day 83, Ocular Surface Disease Index rising from 5.7 to 65.1, Schirmer falling from 8.9 mm to 4.2 mm, and confocal microscopy showing pseudomicrocysts, vortex keratopathy and thinned subbasal nerves. A meta-analysis of 17 studies and 610 eyes with lamellar macular holes and epiretinal proliferation found vitrectomy associated with a pooled 0.170 logMAR gain (95% CI -0.254 to -0.086, heterogeneity zero) while observed eyes changed little, though the two arms were pooled separately rather than compared head to head and full-thickness hole rates overlapped. A deep learning model trained on 207 eyes to time the first anti-VEGF injection in neovascular age-related macular degeneration reached an area under the curve of 0.73 and a sensitivity of 0.69, which is research-stage rather than clinic-ready. In eyes with axial length 32 mm or more, Cooke K6, EVO 2.0, Pearl-DGS and Zhu-Lu all outperformed Hoffer QST, which drifted hyperopic as eyes grew longer.
Intra-arterial chemotherapy salvages cT3b and cT3c retinoblastoma eyes, but not cT3d
For unilateral cT3b or cT3c retinoblastoma, intra-arterial chemotherapy salvaged three to four times as many eyes as intravenous chemotherapy without any survival penalty, while cT3d eyes should still be enucleated promptly.
HER2 antibody-drug conjugates take the tear film and the corneal nerves with them
New blurring and grittiness about five to six weeks into a HER2-targeted antibody-drug conjugate is drug-induced epitheliopathy with subbasal nerve loss until shown otherwise, and needs a documented ocular surface work-up sent back to the oncologist.
Vitrectomy for lamellar holes with epiretinal proliferation: a gain worth having, from two separate pools
Offer vitrectomy to symptomatic eyes with lamellar holes and epiretinal proliferation on the strength of an average 0.17 logMAR gain, but do not sell it as prevention of full-thickness progression.
A model that decides when to start anti-VEGF is not yet good enough to let one wait
This automated treat-now model matched clinicians only moderately, with sensitivity 0.69, so it is a prompt to review a scan rather than a basis for lengthening monitoring intervals.
A child with a squint or a white pupil needs a dilated fundus this week
Every child with new unilateral strabismus or any report of a white pupil gets a dilated fundus examination at the first possible appointment, with examination under anaesthesia if the view is poor.
In eyes longer than 32 mm, drop Hoffer QST and use Cooke K6, EVO, Pearl-DGS or Zhu-Lu
For cataract surgery in eyes of 32 mm or longer, calculate with Cooke K6, EVO 2.0, Pearl-DGS or Zhu-Lu and stop using Hoffer QST, which was least accurate and drifted hyperopic as the eye lengthened.
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