Abstract Case Presentation A 71–year–old woman was referred to our outpatient clinic for two episodes of chest pain during last two days. Her past medical history was remarkable for arterial hypertension, obesity, diabetes mellitus type 2 treated by oral hypoglycaemic agents complicated by diabetic maculopathy. Diagnostic Work–Up At the presentation, the patient was symptomathic for chest pain, hemodynamically stable. The ECG showed synus rhythm, left–axis deviation, Q wave and ST–elevation from V2 to V5 and in DIII and ST–elevation in DII and aVF (FIGURE 1). Transthoracic echocardiography revealed concentric hypertrophy, mildly reduced LV ejection fraction (EF 45%) with akinesia of intreventricular septum and apex, without severe valvulopathies and no pericardial effusion. Given the clinical data the patient was addressed to urgent coronary angiography that showed LAD occlusion at the end of his proximal tract and right coronary artery occlusion at the beggining of his second tract (FIGURE 2); furthermore omo and etero–coronaric collaterals for right coronary artery area were detected. By using a workhorse guidewire flow was restored in both coronary arteries and PTCA was performed with 3 DES on LAD and other 2 DES on right coronary artery (FIGURE 3). The patient was transferred to our coronaric intensive unit care after the procedure; no complications were noticed during the hospitalization. A week after the patient was discharged in good general health. Conclusion Multiple simultaneous coronary occlusions are reported in literature, yet the accurate incidence and physiopathology of this occurrence is still uncertain. Probably the symphathetic system activation caused by first coronary occlusion could promote an increased basal platelets activation and then the second coronary occlusion. Our case shows that during coronary angiography identifying a culprit lesion may be delicate and cardiologists should be prepared to manage multiple coronary occlusions.

Background and objectivesOptical coherence tomography (OCT) has ushered in a transformative era in the domain of ophthalmology, offering non-invasive imaging with high resolution for ocular disease detection. OCT, which is frequently used in diagnosing fundamental ocular pathologies, such as glaucoma and age-related macular degeneration (AMD), plays an important role in the widespread adoption of this technology. Apart from glaucoma and AMD, we will also investigate pertinent pathologies, such as epiretinal membrane (ERM), macular hole (MH), macular dystrophy (MD), vitreomacular traction (VMT), diabetic maculopathy (DMP), cystoid macular edema (CME), central serous chorioretinopathy (CSC), diabetic macular edema (DME), diabetic retinopathy (DR), drusen, glaucomatous optic neuropathy (GON), neovascular AMD (nAMD), myopia macular degeneration (MMD) and choroidal neovascularization (CNV) diseases. This comprehensive review examines the role that OCT-derived images play in detecting, characterizing, and monitoring eye diseases. MethodThe 2020 PRISMA guideline was used to structure a systematic review of research on various eye conditions using machine learning (ML) or deep learning (DL) techniques. A thorough search across IEEE, PubMed, Web of Science, and Scopus databases yielded 1787 publications, of which 1136 remained after removing duplicates. Subsequent exclusion of conference papers, review papers, and non-open-access articles reduced the selection to 511 articles. Further scrutiny led to the exclusion of 435 more articles due to lower-quality indexing or irrelevance, resulting in 76 journal articles for the review. ResultsDuring our investigation, we found that a major challenge for ML-based decision support is the abundance of features and the determination of their significance. In contrast, DL-based decision support is characterized by a plug-and-play nature rather than relying on a trial-and-error approach. Furthermore, we observed that pre-trained networks are practical and especially useful when working on complex images such as OCT. Consequently, pre-trained deep networks were frequently utilized for classification tasks. Currently, medical decision support aims to reduce the workload of ophthalmologists and retina specialists during routine tasks. In the future, it might be possible to create continuous learning systems that can predict ocular pathologies by identifying subtle changes in OCT images.

Introduction: Hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, used in the treatment of renal anemia, hold the potential to increase the production of vascular endothelial growth factors. Therefore, HIF-PH inhibitors may exacerbate retinal hemorrhage in diseases such as diabetic retinopathy. Here, we present a case involving the administration of an HIF-PH inhibitor, resulting in the exacerbation of retinal hemorrhage in a patient with diabetic retinopathy. Case Presentation: A 32-year-old man with diabetes mellitus and renal anemia caused by diabetic nephropathy was referred to our department for ophthalmic examination, revealing diabetic retinopathy with scattered retinal hemorrhages, exudates, and diabetic maculopathy in both eyes. Darbepoetin alfa was initially administered and switched to the HIF-PH inhibitor roxadustat on day 74. By day 88, fresh retinal hemorrhage was observed in the right eye. On day 132, the retinal hemorrhage had further worsened, with new preretinal hemorrhage in both eyes. Roxadustat was discontinued, replaced with darbepoetin alfa, resulting in retinal hemorrhage improvement by day 181 (49 days post-roxadustat cessation). On day 201, fundus hemorrhage further improved, optical coherence tomography showed no macular edema or subretinal fluid, and the retina was thinning. Fluorescein angiography showed neovascular vessels, active fluorescein leakage, and extensive avascular areas in both eyes, prompting pan-retinal photocoagulation. Visual acuity remained stable throughout treatment. Conclusion: Patients with advanced diabetic retinopathy taking HIF-PH inhibitors should be aware of retinal hemorrhage exacerbations. If observed, the treatment plan, including discontinuation of the HIF-PH inhibitor or switching to another agent, should be discussed with a diabetologist, nephrologist, and ophthalmologist.

Diabetic Retinopathy (DR) is a leading cause of blindness worldwide, affecting people with diabetes. The timely diagnosis and treatment of DR are essential in preventing vision loss. Non-mydriatic fundus cameras and artificial intelligence (AI) software have been shown to improve DR screening efficiency. However, few studies have compared the diagnostic performance of different non-mydriatic cameras and AI software. This clinical study was conducted at the endocrinology clinic of Akdeniz University with 900 volunteer patients that were previously diagnosed with diabetes but not with diabetic retinopathy. Fundus images of each patient were taken using three non-mydriatic fundus cameras and EyeCheckup AI software was used to diagnose more than mild diabetic retinopathy, vision-threatening diabetic retinopathy, and clinically significant diabetic macular oedema using images from all three cameras. Then patients underwent dilation and 4 wide-field fundus photography. Three retina specialists graded the 4 wide-field fundus images according to the diabetic retinopathy treatment preferred practice patterns of the American Academy of Ophthalmology. The study was pre-registered on clinicaltrials.gov with the ClinicalTrials.gov Identifier: NCT04805541. The Canon CR2 AF AF camera had a sensitivity and specificity of 95.65% / 95.92% for diagnosing more than mild DR, the Topcon TRC-NW400 had 95.19% / 96.46%, and the Optomed Aurora had 90.48% / 97.21%. For vision threatening diabetic retinopathy, the Canon CR2 AF had a sensitivity and specificity of 96.00% / 96.34%, the Topcon TRC-NW400 had 98.52% / 95.93%, and the Optomed Aurora had 95.12% / 98.82%. For clinically significant diabetic macular oedema, the Canon CR2 AF had a sensitivity and specificity of 95.83% / 96.83%, the Topcon TRC-NW400 had 98.50% / 96.52%, and the Optomed Aurora had 94.93% / 98.95%. The study demonstrates the potential of using non-mydriatic fundus cameras combined with artificial intelligence software in detecting diabetic retinopathy. Several cameras were tested and, notably, each camera exhibited varying but adequate levels of sensitivity and specificity. The Canon CR2 AF emerged with the highest accuracy in identifying both more than mild diabetic retinopathy and vision-threatening cases, while the Topcon TRC-NW400 excelled in detecting clinically significant diabetic macular oedema. The findings from this study emphasize the importance of considering a non mydriatic camera and artificial intelligence software for diabetic retinopathy screening. However, further research is imperative to explore additional factors influencing the efficiency of diabetic retinopathy screening using AI and non mydriatic cameras such as costs involved and effects of screening using and on an ethnically diverse population.

PurposeTo provide automated system for synthesizing fluorescein angiography (FA) images from color fundus (CF) photographs for averting risks associated with fluorescein dye and extend its future application to Space-associated neuro-ocular syndrome (SANS) detection in spaceflight where resources are limited. DesignDevelopment and validation of a novel conditional generative adversarial network (GAN) trained on limited amount of fluorescein angiography and color fundus images with diabetic retinopathy and control cases. ParticipantsColor fundus and fluorescein angiography paired images for unique patients were collected from a publicly available study. MethodsFA4SANS-GAN was trained to generate fluorescein angiography images from color fundus photographs using two multi-scale generators coupled with two patch-GAN discriminators. 850 CF and FA images were utilized for training by augmenting images from 17 unique patients. The model was evaluated on 56 fluorescein images collected from 14 unique patients. In addition, it was compared with three other GAN architectures trained on the same dataset. Furthermore, we test the robustness of the models against acquisition noise and retaining structural information when introduced to artificially created biological markers. Main Outcome MeasureFor GAN synthesis metric Fréchet Inception Distance (FID) and Kernel Inception Distance (KID). Also, two one-sided tests (TOST) based on Welch's t-test for measuring statistical significance. ResultsOn test FA images, mean FID for FA4SANS-GAN was 39.8 (SD 9.9), which is better than GANgio model’s mean of 43.2 (SD 13.7), Pix2PixHD’s mean of 57.3 (SD 11.5) and Pix2Pix’s mean of 67.5 (SD 11.7). Similarly for KID, FA4SANS-GAN achieved mean of 0.00278 (SD 0.00167) which is better than other three model’s mean KID of 0.00303 (SD 0.00216), 0.00609 (SD 0.00238), 0.00784 (SD 0.00218). For TOST measurement, FA4SANS-GAN has proven to be statistically significant vs. GANgio (p = 0.006); vs Pix2PixHD (p < 0.00001); and vs. Pix2Pix (p < 0.00001). ConclusionOur study has shown FA4SANS-GAN to be statistically significant for two GAN synthesis metrics. Moreover, it is robust against acquisition noise, and can retain clear biological markers compared to the other three GAN architectures. This deployment of this model can be crucial in International Space Station (ISS) for detecting Spaceflight-associated neuro-ocular syndrome (SANS).

Retinal lesions, including cotton-wool exudates, microbleeds, vascular occlusions and vasculitis, occur in a minority of Coronavirus Disease-19 (COVID-19) patients. Retinal assessments using retinography can help document these lesions. The objective of this work was to identify retinal changes in patients admitted to the ward with a positive Real Time Quantitative Polymerase Chain Reaction (RT-qPCR) exam for COVID-19. A cross-sectional, observational study was carried out of patients with mild and moderate symptoms admitted to the Hospital de Base in São José do Rio Preto. The Eyer® portable retinal camera (Phelcom® Technologies) was used to evaluate 30 male and 21 female patients. The ages ranged from 21 to 83 years (mean: 47 years). Systemic arterial hypertension was identified in 21 (41.2 %) and diabetes mellitus in 12 (23.5 %) patients. Six (11.7 %) reported worsening visual acuity, however, none of these patients had ocular findings to justify this complaint. Ten patients (19.6 %) had intraretinal hemorrhages; one (1.9 %) had cotton-wool exudates and seven (13.7 %) had dilations of veins. Thirteen patients (25.4 %) had vascular tortuosity and six (11.7 %) had pathological arteriovenous crossings. Portable retinography is useful to evaluate patients admitted to isolation wards due to COVID-19. It is important to remember that some of the patients investigated had comorbidities like diabetic maculopathy and systemic arterial hypertension. Hence, some care should be taken in attributing these observations uniquely to COVID-19 infection.

Aims/Purpose: Today there is no approved medical therapy for hard macular exudates in diabetes and unfortunately this pathology often leads to significant visual loss. Purpose of our study was to assess whether long‐term lipid‐lowering therapy with fenofibrate could reduce the number and extension of massive macular exudates in Type 1 diabetes patients.Methods: There were 46 (92 eyes) Type 1 diabetes persons (18–42 years) with diabetic maculopathy and massive hard exudates included in this study. HbA1C ranging from 6% to 9%. The mean visual acuity was 0.3 ± 0.1. Patients were divided into two groups: main (22 person) and control (24 person). Exclusion criteria: patients on lipid‐lowering drugs, oral contraceptive pills, hormone replacement therapy, pregnant woman, familial hypercholesterolemia, hypothyroidism, chronic liver and kidney disease. All patients in the main group received fenofibrate 145 mg once a day for 8 months, patients in control group had conventional therapy. All patients had undergone standard ophthalmological examination, fundus photos and OCT scanning on presentation and during follow‐up visits. Patients were followed at 2, 6, 12 and 18 months after the start of the treatment.Results: In the main group anatomic result expressed by the reduction of number and extension of hard exudates, decrease in central retinal thickness was achieved in 77% of patients (17 patients, 34 eyes). Central retinal thickness in the main group decreased from mean 392 mkm to 255 mkm ± 30 mkm. Good functional result was achieved in 64% of patients (28 eyes), where visual acuity increased from 0.3 to 0.5 ± 0.1. This effect was stable for the whole follow‐up period. In the control group 74% of patients had no anatomic neither functional changes. In 15% of patients mean visual acuity slightly improved from 0.3 to 0.4 ± 0.05 with decrease in central retinal thickness from mean 386 mkm to 320 mkm ± 30 mkm due to better compensation of the main disease. In 15% the number and extension of hard exudates increased with further vision deterioration. No fenofibrate side effects were noticed in either group.Conclusions: Fenofibrate in Type 1 diabetic patients diminishes number of macular hard exudates, reduces macular oedema, improves visual acuity with stable effect over the time.

In the everyday practice, we are dealing with various level of difficulty, while performing vitreoretinal cases. There are some cases which require high level of skills and experience in order to perform successful and effective surgery. Refractory or myopic macular holes, optic disk pit cases, PVR cases, advanced proliferative diabetic retinopathy cases, trauma cases and paediatric vitreoretinal cases are some examples. The purpose of the SIS is a group of very experienced vitreoretinal surgeons with high volume of cases, to provide tips and pearls in to how to perform safer surgery, with the best results, anatomically and functionally. We will also provide advise into how to use chandelier additional lighting and how to use and remove heavy silicone oil and buckles.

The aim of this study was to study the progression of diabetic retinopathy (DR) and macular edema in uncomplicated phacoemulsification in patients with diabetes mellitus with a follow-up of 6 months. A prospective, nonrandomized study was conducted on patients with established or no DR in a known case of diabetes mellitus undergoing cataract surgery by phacoemulsification, with no intraoperative complications. Detailed ophthalmic evaluation including fundus examination was done in all cases, and DR staging was done. Optical coherence tomography and fundus fluorescein angiography were done in indicated cases. Fundus evaluation was done during the follow-up visits in 3 weeks, 3 months, and 6 months postsurgery and the tests were repeated if necessary. In the current study, there was a statistically significant improvement in best-corrected visual acuity after cataract surgery compared to the preoperative value. From the 330 eyes we analyzed, there was a progression of DR in only 18 eyes (5.45%) following phacoemulsification. There was a statistically significant increase in central macular thickness (CMT) at 3 weeks postoperative (433.82 ± 137.572) compared to that of the preoperative CMT (295.98 ± 97.959). From the 22 eyes which showed a progression of diabetic maculopathy, 11 eyes had developed new-onset macular edema following the cataract surgery, 11 eyes had progression of preexisting edema, and 4 of them had to undergo intravitreal anti-vascular endothelial growth factor injections as the treatment. The chance of progression of DR staging is low after uncomplicated phacoemulsification, on a short term. However, the chances of worsening of macular edema as well as worsening of proliferative stages should be kept in mind while advising a patient for cataract surgery.