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Objective To assess ‘time in range’ as a novel measure of treatment response in diabetic macular oedema (DMO). Methods This post hoc analysis of the Protocol T randomised clinical trial included 660 individuals with centre-involved DMO and best-corrected visual acuity (BCVA) letter score ≤78–≥24 (approximate Snellen equivalent 20/32–20/320). Study participants received intravitreal aflibercept 2.0 mg, repackaged (compounded) bevacizumab 1.25 mg, or ranibizumab 0.3 mg given up to every 4 weeks using defined retreatment criteria. Mean time in range was calculated using a BCVA letter score threshold of ≥69 (20/40 or better; minimum driving requirement in many regions), with sensitivity analyses using BCVA thresholds from 100 to 0 (20/10 to 20/800) in 1-letter increments. Results Time in range was defined as either the absolute or relative duration above a predefined BCVA threshold, measured in weeks or as a percentage of time, respectively. Using a BCVA letter score threshold of ≥69 (20/40 or better), the least squares mean time in range (adjusted for baseline BCVA) in Year 1 was 41.2 weeks with intravitreal aflibercept, 4.0 weeks longer (95% CI: 1.7, 6.3; p = 0.002) than bevacizumab and 3.6 weeks longer (1.3, 5.9; p = 0.004) than ranibizumab. Overall, mean time in range was numerically longer for intravitreal aflibercept for all BCVA letter score thresholds between 92 and 30 (20/20 to 20/250). In the Day 365–728 analysis, time in range was 3.9 (1.3, 6.5) and 2.4 (0.0, 4.9) weeks longer with intravitreal aflibercept vs bevacizumab and vs ranibizumab (p = 0.011 and 0.106), respectively. Conclusion BCVA time in range may represent another way to describe visual outcomes and potential impact on vision-related functions over time for patients with DMO and provide a better understanding, for physicians and patients, of the consistency of treatment efficacy.

OBJECTIVES For patients with polypoidal choroidal vasculopathy (PCV), intravitreal anti-vascular endothelial growth factor (anti-VEGF) combination therapy has been shown to be cost-saving relative to monotherapy in a clinical trial setting. However, whether this also applies to real-world settings is unclear. We aim to compare the real-world functional outcomes and cost-effectiveness of intravitreal anti-VEGF combination therapy relative to monotherapy, to investigate whether combination therapy is truly cost-saving. METHODS We used a Markov model to simulate a hypothetical cohort of PCV patients treated at Singapore National Eye Centre. Model parameters were informed by coarsened exact matched estimates of a two-year retrospective study of patients who initiated treatment in 2015. Treatment options included intravitreal aflibercept, bevacizumab, or ranibizumab, as monotherapy or in combination with full-fluence verteporfin photodynamic therapy. RESULTS The two-year logMAR letters gains were significant for combination therapy ( + 10.6, P = 0.006) but not monotherapy (-2.2, P = 0.459). Over 20 years, a PCV patient would cost the health system SGD 48,790 under monotherapy and SGD 61,020 under combination therapy. Quality-adjusted life-years (QALYs) were estimated to be 7.41 for monotherapy and 7.80 for combination therapy. The incremental cost-effectiveness ratio of combination therapy was SGD 31,460/QALY, which is less than the common willingness-to-pay threshold of per capita gross domestic product of Singapore (SGD 88,990/QALY). Sensitivity analysis showed that combination therapy remained incrementally cost-effective, but not cost-saving. CONCLUSIONS Our study shows that combination therapy is good value for money but is likely to increase costs when applied in real-world settings.

Aim The aim of this study is to evaluate the frequency and types of anti-retinal autoantibodies (ARAs) in highly myopic patients and to explore any association between ARAs and the severity of myopic macular degeneration (MMD). Methods This was a clinic-based study of 16 patients with high myopia (spherical equivalent worse than -6 dioptres or axial length (AL) ≥ 26.5 mm) recruited from the High Myopia clinic of the Singapore National Eye Centre. MMD was graded from fundus photographs according to the Meta-analysis for Pathologic Myopia (META-PM) classification. Severe MMD was defined as META-PM category 3 or 4. AL and logarithm of the minimal angle of resolution (logMAR) best corrected visual acuity (BCVA) were measured. Sera were obtained from subjects and analysed for the presence of ARAs with the western blot technique. Results The mean AL was significantly longer in patients with severe MMD (n = 8) than those without severe MMD (n = 8) (31.50 vs. 28.51, p = 0.005). There was at least one ARA identified in all patients. The most common ARA was anti-carbonic anhydrase II (anti-CAII), present in nine patients (56.3%). Anti-CAII was detected in more patients with severe MMD than those without (75 vs. 37.5%, p = 0.32). LogMar BCVA was also worse in subjects with anti-CAII (0.5 ± 0.38 vs. 0.22 ± 0.08, p = 0.06). The number of ARAs significantly correlated with increasing AL (r = 0.61, p = 0.012). Conclusions ARAs are prevalent in patients with high myopia, and this increases with increasing AL. In particular, anti-CAII antibodies were highly prevalent in patients with severe MMD, suggesting that ARAs may be associated with MMD. Further studies are necessary to confirm these observations in larger cohorts.

The prevalence of myopia is increasing globally. Complications of myopia are associated with huge economic and social costs. It is believed that high myopia in adulthood can be traced back to school age onset myopia. Therefore, it is crucial and urgent to implement effective measures of myopia control, which may include preventing myopia onset as well as retarding myopia progression in school age children. The mechanism of myopia is still poorly understood. There are some evidences to suggest excessive expansion of Bruch's membrane, possibly in response to peripheral hyperopic defocus, and it may be one of the mechanisms leading to the uncontrolled axial elongation of the globe. Atropine is currently the most effective therapy for myopia control. Recent clinical trials demonstrated low-dose atropine eye drops such as 0.01% resulted in retardation of myopia progression, with significantly less side effects compared to higher concentration preparation. However, there remain a proportion of patients who are poor responders, in whom the optimal management remains unclear. Proposed strategies include stepwise increase of atropine dosing, and a combination of low-dose atropine with increase outdoor time. This review will focus on the current understanding of epidemiology, pathophysiology in myopia and highlight recent clinical trials using atropine in the school-aged children, as well as the treatment strategy in clinical implementation in hyperopic, pre-myopic and myopic children.摘要: 全球近视的患病率正在急剧上升, 且近视的并发症消耗巨大的社会和财政支出。人们认为, 成年后的高度近视由学龄期发生的近视而来。因此, 实施近视控制的有效措施至关重要, 措施包括预防近视产生以及延缓学龄儿童的近视发展。目前, 然而关于近视的致病机制仍然知之甚少。一些证据表明Bruch膜的过度扩张, 可能引起了周边远视离焦, 并且它可能是导致眼球发生不可控制的眼轴伸长的机制之一。阿托品是目前控制近视最有效的方法。最近的临床试验表明, 与高浓度制剂相比, 低剂量阿托品滴眼液如0.01% 可以延缓近视发展, 副作用明显减少。然而, 仍然有一部分患者的反应较差, 其中最佳处理仍不明确。已提出的临床策略包括逐步增加阿托品给药频率, 以及低剂量阿托品结合增加室外活动时间。本综述将重点介绍目前近视在流行病学、病理生理学中的研究, 以及最近在学龄儿童中使用阿托品的临床试验和临床实施的远视、近视、近视儿童的治疗策略。.

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the defining event of this generation. To date, there are over 2 million cases including more than 145,000 deaths with this number constantly rises day by day. The lack of a cure or a viable vaccine has resulted in the implementation of extreme social distancing measures with lockdowns declared in many countries to minimise person-to-person interactions to prevent the transmission of the virus. These measures have a profound impact on health care provision. A few sub-specialities such as ENT, anaesthesia and ophthalmology are considered to be at higher risk than others due to the close proximity to patients and the nature of procedures associated with higher transmission risk.

Sir, Since Aflibercept became commercially available, there have been several publications describing favourable early experience, particularly in cases previously refractory to other anti-vascular endothelial growth factor (anti-VEGF) and cases with persistent pigment epithelial detachment (PED).1, 2, 3, 4, 5 However, there is very little clinical experience of Aflibercept in polypoidal choroidal vasculopathy. We present our favourable experience with Aflibercept in the treatment of persistent PED after photodynamic therapy (PDT) combined with Ranibizumab.