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Systemic sclerosis (SSc) is a chronic multisystemic disease characterized by immunological activation, diffuse vasculopathy, and generalized fibrosis exhibiting a variety of symptoms. A recognized precursor of SSc is Raynaud's phenomenon, which is part of the very early disease of systemic sclerosis (VEDOSS) in combination with nailfold videocapillaroscopy (NVC) impairment. The pathophysiology of ocular involvement, alterations in internal organs, and body integumentary system involvement in SSc patients are complicated and poorly understood, with multiple mechanisms presumptively working together. The most prevalent ocular symptoms of SSc are abnormalities of the eyelids and conjunctiva as well as dry eye syndrome, due to fibroblasts' dysfunction and inflammation of the ocular surface. In particular, lagophthalmos, blepharophimosis limitation of eyelid motion, eyelid telangiectasia, and rigidity or tightening of the lids may affect up to two-third of the patients. In addition, reduction in central corneal thickness, iris defects and higher rates of glaucoma were reported. In the first reports based on retinography or fluorescein angiography, about 50% of SSc patients showed signs of vascular disease: peripheral artery occlusion, thinning of retinal pigment epithelium and choroidal capillaries, ischemic areas surrounded by intraretinal extravasation and microaneurysms, and peripheral capillary non-perfusion. Successively, thanks to the advent of optical coherence tomography angiography (OCTA), several studies highlighted significant impairment of either the choriocapillaris and retinal vascular plexuses, also correlating with NVC involvement and skin disease, even in VEDOSS disease. Given the sensitivity of this technique, ocular micro-vasculopathy may act as a tool for early SSc identification and discriminate between disease stages. [ABSTRACT FROM AUTHOR]

Purpose: This review focuses on extensive macular atrophy with pseudodrusen-like appearance (EMAP), a recently described maculopathy presenting with pseudodrusen-like lesions and chorioretinal atrophy more pronounced in the vertical axis. Methods: Narrative review of the literature published until May 2024. Results: The early onset age of EMAP (50–55 years) and its distinctive natural history, which includes night blindness followed by severe vision loss, differentiate it from atrophic age-related macular degeneration (AMD). A clear pathogenesis has not been determined, but risk factors include female gender and complement system abnormalities (altered levels of C3 and CH50). Moreover, lifelong exposure to pesticides has been suggested as risk factor for direct neuronal degeneration involving rods and cones. In the early phase of the disease, reticular pseudodrusen-like lesions appear in the superior perifovea and tend to coalescence horizontally into a flat, continuous, reflective material localized between the retinal pigmented epithelium and Bruch's membrane. Over time, EMAP causes profound RPE and outer retinal atrophy in the macular area, with a recent classification reporting a 3-stages evolution pattern. Blue autofluorescence showed rapidly evolving atrophy with either hyperautofluorescent or isoautofluorescent borders. Significant similarities between the diffuse-trickling phenotype of geographic atrophy and EMAP have been reported. Macular neovascularization is a possible complication. Conclusion: EMAP is specific form of early-onset atrophic macular degeneration with rapid evolution and no treatment. Further studies are needed to assess the best management. Key messages: What is known • Extensive Macular Atrophy with Pseudodrusen (EMAP) is a rapidly-progressive macular atrophy developing in the fifth-decade and leading to legal blindness. • Typical characteristics at multimodal imaging are reticular pseudodrusen-like lesions starting at the superior perifovea and vertically-oriented macular atrophy. What is new • Dysregulated complement cascade and pesticide-related toxicity have been proposed as possible etiologies. • In the late stages of the disease 50% of EMAP patients were legally blind by US standards and, after 7 years on average, atrophy reaches the mid-periphery. [ABSTRACT FROM AUTHOR]

Background We aimed to define the capability of three different publicly available large language models, Chat Generative Pretrained Transformer (ChatGPT-3.5), ChatGPT-4 and Google Gemini in analysing retinal detachment cases and suggesting the best possible surgical planning. Methods Analysis of 54 retinal detachments records entered into ChatGPT and Gemini's interfaces. After asking 'Specify what kind of surgical planning you would suggest and the eventual intraocular tamponade.' and collecting the given answers, we assessed the level of agreement with the common opinion of three expert vitreoretinal surgeons. Moreover, ChatGPT and Gemini answers were graded 1-5 (from poor to excellent quality), according to the Global Quality Score (GQS). Results After excluding 4 controversial cases, 50 cases were included. Overall, ChatGPT-3.5, ChatGPT-4 and Google Gemini surgical choices agreed with those of vitreoretinal surgeons in 40/50 (80%), 42/50 (84%) and 35/50 (70%) of cases. Google Gemini was not able to respond in five cases. Contingency analysis showed significant differences between ChatGPT-4 and Gemini (p=0.03). ChatGPT's GQS were 3.9±0.8 and 4.2±0.7 for versions 3.5 and 4, while Gemini scored 3.5±1.1. There was no statistical difference between the two ChatGPTs (p=0.22), while both outperformed Gemini scores (p=0.03 and p=0.002, respectively). The main source of error was endotamponade choice (14% for ChatGPT-3.5 and 4, and 12% for Google Gemini). Only ChatGPT-4 was able to suggest a combined phacovitrectomy approach. Conclusion In conclusion, Google Gemini and ChatGPT evaluated vitreoretinal patients' records in a coherent manner, showing a good level of agreement with expert surgeons. According to the GQS, ChatGPT's recommendations were much more accurate and precise. [ABSTRACT FROM AUTHOR]

We report a case of personalized exclusive brachytherapy treatment for the management of a highly recurrent squamous cell conjunctival carcinoma with corneal invasion. This is a case of a Caucasian 81-years-old man who presented 10 years ago to our clinic with a pink-white para-limbal mass with dilated feeder arteries and mild leukoplakia. Excisional biopsy confirmed the presence of conjunctival intraepithelial neoplasia (CIN). Successively, he underwent two 4-weeks cycles of Mytomicin C topical therapy and a second excisional surgery, due to several recurrences of the lesion. At the last relapse, the pink-white peri-limbic mass which invaded the corneal limbus, determining corneal opacification from 5- to 7-clock hours, was confirmed by anterior segment optical coherence tomography (AS-OCT). Due to resistance to MMC therapy and chronic epitheliopathy, an AS-OCT guided exclusive radiotherapy plan was set: a Rhutenium-106 CCD plaque was applied directly over the afflicted corneal surface, the corneal limbus and the neighboring sclera for 24 hours. The remission of both conjunctival and corneal malignancy was complete 2 months after surgery and no signs of recurrence were highlighted at AS-OCT analysis at the 2-year follow up. Brachytherapy treatment showed optimal management of both corneal and conjunctival involvement, with a free-of-disease follow-up of 24-months. This result suggests that, in specific conditions, Ru-106 brachytherapy could be an effective option of treatment even if not associated with surgical excision. [ABSTRACT FROM AUTHOR]

The ranibizumab (RBZ) port delivery system (PDS) is a device designed to continuously deliver RBZ in the vitreous chamber for the treatment of neovascular age-related macular degeneration (nAMD). It is implanted during a surgical procedure and can provide sustained release of the medication for several months. This review, updated to January 2024, focuses on past clinical studies as well as current and forthcoming trials looking into a PDS with RBZ. In the phase 2 LADDER trial, the mean time to first refill of a PDS with RBZ 100 mg/mL was 15.8 months, with the pharmacokinetic (PK) profile showing a sustained concentration of RBZ in the blood and aqueous humor. More recently, a PDS with RBZ (100 mg/mL) refilled every 24 weeks was shown to be non-inferior to a monthly intravitreal injection (IVI) with RBZ (0.5 mg) over 40 and 92 weeks in the phase 3 ARCHWAY trial. The refill every 24 weeks allowed for a RBZ vitreous exposure within the concentration range of monthly intravitreal injections (IVIs), and the expected half-life (106 days) was comparable with the in vitro results. Nonetheless, vitreous hemorrhage and endophthalmitis were more common side effects in PDS patients. In conclusion, a PDS continuously delivering RBZ has a clinical effectiveness level comparable with IVI treatment. However, a greater frequency of unfavorable occurrences highlights the need for procedure optimization for a wider adoption. Ongoing trials and possible future approaches need to be addressed. [ABSTRACT FROM AUTHOR]

Background: We aimed to explore microvascular changes evaluated with optical coherence tomography angiography (OCTA) in patients undergoing epiretinal membrane (ERM) pars-plana vitrectomy (PPV) combined with intravitreal Ozurdex implantation, compared with standard PPV. (2) Methods: Prospective interventional analysis on 25 eyes undergoing PPV + Ozurdex (Group A) and 25 eyes undergoing PPV alone. Best corrected visual acuity (BCVA) and OCTA parameters, such as vessel density (VD) of the superficial and deep capillary plexi (SCP and DCP) in the whole 6.4 mm × 6.4 mm and fovea area, were evaluated preoperatively and 3 months after surgery. (3) Results: Postoperative BCVA significantly improved in both groups. No cases of post-operative cystoid macular edema (CME) were reported in Group A vs. two eyes in Group B. In Group A we found a statistically significant increase of SCP's VD in either the whole image (from 42.1 ± 4.1 to 45.6 ± 4.3%, p = 0.01) and the fovea image (from 38.5 ± 7.5 to 41.7 ± 4.2%, p = 0.03). In Group B, we reported no significant variations in the SCP's VDs. In the DCP, VD significantly increased only in the whole image in Group A. Stage 4 ERMs showed the greatest improvement in VD, especially in Group A. (4) Conclusions: Intraoperative Ozurdex prompted a significant BCVA recovery and limited the occurrence of postoperative CME compared to the standard procedure. Moreover, Ozurdex implant is associated with a better restoration of microvascular structure in SCP and DCP. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the impact of PreserFlo Microshunt on the ocular surface, focusing on both objective and subjective parameters. Methods: Prospective‐observational study on 48 eyes undergoing PreserFlo Microshunt implantation, standalone or combined with phacoemulsification. At baseline, 1‐month, 6‐months and 12‐months post‐operative follow‐ups, we performed Ocular Surface Disease Index (OSDI) questionnaire, Schirmer's test (ST), Tear‐film break‐up time (TBUT), fluoresceine staining (FS), tear osmolarity and minimum corneal epithelial thickness (Epi‐ThkMIN.) measurements. Results: OSDI score improved from 37.43 ± 17.49 at baseline, to 24.13 ± 12.55 at 1‐month (p = 0.003) and to 12.89 ± 8.54 and 13.09 ± 10.22 at 6‐months and 12‐months (p < 0.0001). TBUT and ST, in a similar way, non‐significantly increased at 1‐month, but then improved at 6‐months and 12‐months (p < 0.05 for both). Tear osmolarity significantly decreased from 308.2 ± 7.3 mOsm/L at baseline, to 303.3 ± 8.2 mOsm/L, 295.6.2 ± 7.0 mOsm/L and 297.6 ± 6.8 mOsm/L at 1‐month, 6‐months and 12‐months (p < 0.05 for all). Epi‐ThkMIN was stable when comparing baseline (44.9 ± 5.7 μm) and 1‐month (p = 0.28), and successively increased in 6‐months (47.8 ± 5.5 μm, p = 0.02) and 12‐months (48.0 ± 3.6 μm, p = 0.01). In subgroup analysis, OSDI score and tear osmolarity were significantly higher at 1‐month in combined group compared to standalone group (p = 0.03 and p = 0.02, respectively), but reaching comparable values in successive follow‐ups. Further, Oxford scale grades for FS were significantly improved when comparing baseline–6‐months and baseline–12‐months. Conclusion: PreserFlo implantation improved ocular surface subjective symptoms, increased TBUT and ST, and reduced FS, highlighting the potential benefits of this surgical intervention. Moreover, we reported significant improvements of tear osmolarity and corneal epithelium. [ABSTRACT FROM AUTHOR]

Fabry disease (FD) is an X-linked lysosomal storage disorder, causing Gb-3 (globotriaosylceramide) buildup in cellular lysosomes throughout the body, in particular in blood vessel walls, neuronal cells, and smooth muscle. The gradual accumulation of this glycosphingolipid in numerous eye tissues causes conjunctival vascular abnormalities, corneal epithelial opacities (cornea verticillata), lens opacities, and retinal vascular abnormalities. Although a severe vision impairment is rare, these abnormalities are diagnostic indicators and prognostics for severity. Cornea verticillata is the most common ophthalmic feature in both hemizygous men and heterozygous females. Vessel tortuosity has been linked to a faster disease progression and may be useful in predicting systemic involvement. New technologies such as optical coherence tomography angiography (OCTA) are useful for monitoring retinal microvasculature alterations in FD patients. Along with OCTA, corneal topographic analysis, confocal microscopy, and electro-functional examinations, contributed to the recognition of ocular abnormalities and have been correlated with systemic involvement. We offer an update regarding FD ocular manifestations, focusing on findings derived from the most recent imaging modalities, to optimize the management of this pathology. [ABSTRACT FROM AUTHOR]

Background: Complicated cataract surgery is the main cause of secondary lens implantation surgery. Several approaches have been introduced to face those circumstances. As it concerns scleral-fixated IOLs for the posterior chamber, many types of IOL can be implanted. The aim of article is to review the single piece sutureless scleral fixation Carlevale lens; Methods: Narrative review; Results: Several works described as safe the IOL implantation utilizing the handshake approach, without tactile manipulation, which allows for self-centration and lens firm fixation in uncomplicated surgery. This allows to reduce high order aberration such as astigmatism and coma, with a very good postoperative BCVA Conclusions: Carlevale lens is one of the best option to manage insufficient capsular support. [ABSTRACT FROM AUTHOR]

We evaluated a new surgical technique for treating primary rhegmatogenous retinal detachment (RRD), consisting of localized vitrectomy near the retinal break associated with drainage of subretinal fluid without infusion. Twelve eyes of twelve patients with primary RRDs with macula-on superior, temporal, and/or nasal quadrants' RRD with retinal breaks between 8 and 4 o'clock, pseudophakic or phakic eyes, were enrolled. All eyes underwent a two-port 25-gauge vitrectomy with localized removal of the vitreous surrounding the retinal break(s), followed by a 20% SF6 injection and cryopexy. The difference between pre-operative (T0) and post-operative mean BCVA at 6 months follow-up (T6) was not statistically significant (0.16 logMAR vs. 0.21 logMAR; p = 0.055). Primary anatomic success at 6 months was achieved by 86% of patients. No other complications, except for two retinal re-detachments linked to an incorrect head position of the patients, were recorded. Although further studies are necessary to evaluate the treatment's efficacy, we believe our technique could be considered a valid alternative for managing primary RRD. [ABSTRACT FROM AUTHOR]

Human amniotic membranes (hAMs) are extraembryonic tissues currently employed in the treatment of many ocular and systemic diseases. Several reports indicate that hAMs can suppress the signaling pathway of tissue growth factor beta (TGF-β), a cytokine that plays a major role in the pathogenesis of proliferative vitreoretinopathy (PVR) through the induction of epithelial-mesenchymal transition (EMT) in exposed retinal pigmented epithelium (RPE) cells. The present study was conducted to evaluate the efficacy of a modified vitrectomy procedure (hAMP-V) involving the extensive coverage of exposed RPE with hAM patches to prevent postoperative PVR in a series of 15 cases of retinal detachment complicated by severe preoperatory PVR. The primary outcome was to assess the rate of successful retinal reattachment of a single hAMP-V procedure at 6 months from silicone oil removal. Secondary outcomes included the collection of intraoperative data concerning the quantity, size, and scope of hAM patches, and the assessment of postoperative improvements in mean LogMar BCVA at 3 and 6 months. Successful retinal reattachment was obtained in 14 out of 15 eyes (93.3%). Surgical failure due to major recurrence of PVR occurred in 1 out of 15 eyes (6.7%). Postoperative improvements in mean LogMar BCVA were statistically significant (p < 0.05, paired t-test). No intraoperative and postoperative adverse effects were reported. The study helped to refine the surgical technique while also offering cues for future improvements. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to provide intraoperative data demonstrating a significant difference in the membrane peeling dynamics performed under a perfluorocarbon (PFCL) bubble, compared to normal balanced saline solution (BSS). Methods: This is a prospective, interventional, single-center study on a series of 36 consecutive eyes of 36 patients affected by primary epiretinal membrane (ERM). Eighteen eyes underwent standard ERM peeling, while 18 eyes received a PFCL-assisted procedure. Intraoperative optical coherence tomography (iOCT) B-Scans were collected to evaluate the displacement angle (DA) between the underlying retinal plane and the flap of epiretinal tissue, along with the number of times the surgeon had to grab the flap during the intervention. Follow-up visits were carried out at postoperative week 1 and months 1, 3 and 6. Results: The mean DA was 164.8° ± 4.0 in the PFCL-assisted group and 119.7° ± 8.7 in the standard group, with a statistically significant difference between groups (p < 0.001). Moreover, we found a significant difference in the amount of ERM grabs between the two groups (7.2 ± 2.5 in the PFCL-assisted group vs. 10.3 ± 3.1 in the standard group, p = 0.005). The mean BCVA and metamorphopsia significantly improved in both groups (p < 0.05), with no significant intergroup difference at all follow-up visits. Similarly, CST significantly decreased in both groups, and final CST was similar between the two groups (p = 0.719). Overall, three eyes in the standard group developed postoperative dissociated optic nerve fiber layer (DONFL, 16.6%), compared to none of the PFCL-assisted group. Conclusion: We reported a statistically significant difference in the intraoperative peeling dynamics of the PFCL-assisted group, accounting for a decreased tendency in the tearing of the ERM flap and possibly reduced damage to the fiber layer, with equal effectiveness in improving visual function and foveal thickness. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to explore the early efficacy and safety of treatment with intravitreal injections (IVIs) of brolucizumab in patients presenting with neovascular age-related macular degeneration (nAMD) in a real-world setting. Methods: This retrospective study included 194 eyes of 180 patients with nAMD treated with standard 6-mg IVIs of brolucizumab in our clinic between March 11, 2021, and June 15, 2022. Both treatment-naive (33 eyes) and switch therapy patients (161 eyes) were included in the study. Best corrected visual acuity (BCVA), central subfield thickness (CST), retinal fluid distribution (classified as intraretinal, subretinal, under the pigmented epithelium), treatment intervals, and adverse event rates were collected for analysis. Results: Average follow-up time was 37.2 ± 16.6 weeks. Mean baseline BCVAs were 38.1 ± 4.5 and 41.9 ± 6.7 letters in the treatment-naive and switch therapy groups, with a final gain of 16.0 ± 4.9 (p < 0.0001) and 10.7 ± 5.9 (p < 0.0001) letters in the two groups, respectively. Throughout the study period, CST significantly decreased in both treatment naïve (from 352.0 ± 129.4 to 284.2 ± 93.8 µm; p = 0.0015) and switch therapy (from 369.9 ± 140.5 to 307.4 ± 123.5 µm; p < 0.0001). Significant fluid control rates were achieved at the end of the study period (45% and 27% eyes were completely free of fluid in naïve and switch groups, respectively). Five eyes (2.6%) developed adverse events with different grades of intraocular inflammation and visual outcomes. Conclusion: Brolucizumab IVI showed very good anatomical and functional outcomes in both naive and switch patients in this real-world experience. Nevertheless, even showing a favorable risk/benefit profile, clinicians and patients should be aware of the possibility of a small rate of severe complications. [ABSTRACT FROM AUTHOR]

Background: We evaluated changes in both macular and peripapillary vascular parameters, evaluated by OCT angiography (OCTA), after uncomplicated cataract surgery, as well as the influence of effective phacoemulsification time (EPT) and cumulative dissipated energy (CDE). Methods: This is prospective study on 130 eyes of 65 individuals who underwent unilateral phacoemulsification, with fellow eyes data taken as control group. We collected cataract grading, EPT and CDE. Best corrected visual acuity (BCVA), superficial vessel density, deep vessel density, foveal avascular zone (FAZ) parameters and peripapillary capillary density were measured at baseline, one week and one month following surgery. Results: When compared to baseline, there was a significant increase in both superficial and deep foveal density at last follow up (from 42.9 ± 4.2 and 37.3 ± 7.4 to 45.6 ± 5.4 and 43.7 ± 9.0%, p = 0.002 and p = 0.0001, respectively). Both foveal avascular zone's area and perimeter showed a significant decrease compared to the preoperative value (p < 0.05). On the other hand, peripapillary vascular density showed a significant increase at week one (from 49.6 ± 2.7 to 51.4 ± 4.6%, p = 0.01), which returned to preoperative values at last follow up (49.3 ± 4.0%, p = 0.95). We found no significant differences when dividing the cohort for cataract severity. Moreover, no significant effect of the EPT and CDE on vascular changes were reported. Conclusions: We found a significant increase in the vascular parameters of the macular area after cataract surgery, while peripapillary vascular density only experienced a transient increase, suggesting an adaptative metabolic mechanism in response to increased light exposure after surgery. [ABSTRACT FROM AUTHOR]

Macular neovascularization (MNV) and geographic atrophy can complicate age-related macular degeneration (AMD) and lead to severe visual acuity reduction. Despite the medical treatments available, with a defect in the retinal pigmented epithelium (RPE) there is no possibility of restoring acceptable visual acuity. We evaluated postoperative outcomes in patients affected by advanced AMD who underwent subretinal implant of the human amniotic membrane (hAM) as a source of pluripotent stem cells. This retrospective, consecutive, non-randomized interventional study included 23 eyes of 21 patients affected by AMD complicated by MNV, and five eyes of five patients affected by geographic atrophy. All eyes underwent a pars plana vitrectomy, neovascular membrane removal for the MNV group, a subretinal implant of hAM, and gas tamponade, and were followed for 12 months. The primary study outcome was visual acuity improvement. Secondary outcomes were postoperative complications, OCT-angiography parameters correlated with best-corrected visual acuity (BCVA) and MNV recurrence. The mean preoperative BCVA was 1.9 logMAR, and the mean final BCVA value was 1.2 logMAR. In the MNV group, the mean BCVA improved from 1.84 logMAR to 1.26 logMAR, and from 1.84 logMAR to 1.32 logMAR in the geographic atrophy group. No MNV recurrence was evident in 12 months of follow-up. An OCT-angiography scan was used to evaluate the retinal vascularization in the treated eye, which showed a high correlation between BCVA and deep vascular density. This study demonstrates the hAM potential and safety in promoting a partial restoration of retinal function together with an increase in visual acuity. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to compare the morphology of six-month follow-up blebs created by a subconjunctival glaucoma surgical device (XEN45) to those created by a PreserFlo MicroShunt with a sub-Tenon insertion, utilizing AS-OCT. Methods: A retrospective study of 29 eyes who underwent XEN45 implantation and 29 eyes who underwent PreserFlo MicroShunt implantation. The patients were analyzed at 24 h, 1 week, 1 month, 3 months and 6 months. At each visit, the maturation and morphological alterations of the blebs were observed, as well as connections with the IOP. Results: In both groups, IOP showed significant reduction at all follow ups (p < 0.0001). In XEN group, the most common bleb morphology in the immediate postoperative was the subconjuntival separation type (42%) followed by the uniform type (34%), with a trend inversion at 6 month follow up (51% of uniform type). On the contrary, the most common morphology after PreserFlo was the multiple internal layer (55%), which showed a tendency to reduce over time and was substituted by the microcystic multiform, whose percentage increased over time (17% at day 1 vs. 44% at month 6). Uniform appearance was associated by the posterior episcleral fluid (PEF) lake presence. Both horizontal and vertical diameters significantly increased over time. Conclusion: XEN and PreserFlo implantation resulted in the production of diffuse blebs with different characteristics, which may influence IOP lowering capacity and bleb revisions necessity over time. [ABSTRACT FROM AUTHOR]

Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 μm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher > 90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery. [ABSTRACT FROM AUTHOR]

Intraoperative optical coherence tomography (iOCT) is a noninvasive imaging technique that gives real-time dynamic feedback on surgical procedures. iOCT was first employed in vitreoretinal surgery, but successively served as a guidance in several anterior segment surgical approaches: keratoplasty, implantable Collamer lens (ICL) implantation, and cataract surgery. Among all of those approaches, the unbeatable features of iOCT are fully exploited in anterior and posterior lamellar keratoplasty, and the purpose of this review is to focus on the advantages and shortfalls of iOCT in these techniques, in order to assess whether this technology could be a real step forward. In deep anterior lamellar keratoplasty (DALK), iOCT is useful to evaluate the needle depth into the corneal stroma, the big bubble dissection plane, and residual stromal bed, thus aiding the standardization of the technique and the reduction of failures. In Descemet stripping automated endothelial keratoplasty (DSAEK), iOCT allowed for clear visibility of fluid at the graft/host interface, allowing for immediate rescue maneuvers and granting the best graft apposition. In Descemet membrane endothelial keratoplasty (DMEK), iOCT can track the lenticule unfolding in real time and assess graft orientation even in severe hazy corneas, thus optimizing surgical times, as well as avoiding the use of potentially hazardous exterior markers (such as the "S" stamp) and preventing unnecessary manipulation of the graft. Overall, the role of iOCT appeared crucial in several complicated cases, overcoming the difficulties of poor visualization in a fast, non-invasive way, thus raising this approach as possible gold standard for challenging conditions. Further improvements in the technology may enable autonomous centering and tracking, overcoming the current constraint of instrument-induced shadowing. [ABSTRACT FROM AUTHOR]