The review aims to discuss effects of vitrectomy on pharmacokinetics of anti-vascular endothelial growth factor (anti-VEGF) agents, and attempt to provide treatment guidance. Areas covered: An Embase search was conducted using the terms 'anti-VEGF', 'pegaptanib', 'ranibizumab', 'bevacizumab', 'aflibercept', 'pharmacokinetics', 'half-life', 'clearance', 'metabolism', 'vitrectomy', 'vitrectomized'. Published data regarding the pharmacokinetic properties of the above drugs and the effect of vitrectomy in animal and human eyes was reviewed. Expert opinion: There are limited studies on the effect of vitrectomy on pharmacokinetic properties of anti-VEGF drugs in human eyes. Most animal models indicate that intravitreal drugs have reduced half-lives and increased clearance in vitrectomized eyes. More studies, with carefully selected design, are required to explore this further. However, considering existing evidence, it is important to consider vitreous and lens status when monitoring and treating patients. Authors recommend fixed monthly dosing, with low threshold for increasing frequency of injection even to 2-weekly if required, as well as close monitoring of patients to establish individual response. There may be an increased role for slow-release steroid implants in vitrectomized eyes with DME or RVO. Longer acting substances currently under development such as brolucizumab or abicipar pegol, may become the treatment of choice in the future.

Patients with DME can have reduced reading speed despite good visual acuity. Maximal reading speed is often reported to be difficult to perform, inconsistent, and affected by language and educational level. However, in this study, the authors found that the central MP4 points are quick and easy to test in most of the patients, and are highly correlated with MRS. Microperimetry might therefore represent a useful additional functional test that could be considered better than BCVA or reading speed in quantifying visual function in patients with DME.

BACKGROUND/AIMS: Oculoplastics is a predominantly visual specialty and many of the pathologies can be diagnosed based on external appearance. An image-based eyelid lesion management service was piloted to reduce the number of patients who would require outpatient clinic review. The aim of this study was to determine its accuracy and feasibility, both as a hospital-based and community optometrist-based service. If successful, the service was envisaged to significantly reduce the number of patients that require face-to-face (F2F) review, in accordance with current post-COVID-19 principles of social distancing. METHODS: Patients with lid lesions attending an oculoplastics clinic were assessed by consultant oculoplastic surgeons in an F2F consultation (Arm A). The lesions were photographed by a professional clinical photographer (Arm B) and by an optometrist with a handheld digital camera (Arm C). These images were reviewed by independent consultants masked to the outcome of the F2F clinical encounter. Data were collected prospectively including patient demographics, diagnosis, suspicion of malignancy and management. The image-based clinic results were compared to the F2F clinic results. RESULTS: Ninety-five patients were included. Clinical diagnoses were compared for intra-observer variability and substantial agreement was demonstrated between gold-standard F2F clinic visit (Arm A) and Arm B (Ƙ = 0.708) and C (Ƙ = 0.776). There was no statistically significant difference in the rate of discharge and all cases of malignancy were either identified or flagged for F2F review in the image-based arms. CONCLUSION: This pilot demonstrated substantial diagnostic agreement of image-based diagnoses with F2F consultation and image review alone did not miss any cases of malignancy.

Background: Orthoplastic operations for lower limb osteomyelitis (LLOM) involving microvascular free tissue reconstructions ("free-flaps") are usually performed under general anaesthesia (GA), with or without epidural anaesthesia (EA) due to concerns about the discomfort associated with prolonged surgery. However, our clinical experience supports "awake" epidural anaesthesia with sedation (EA þ Sed) rather than EA þ GA as a technique of choice for this type of surgery.Methods: We used a standardised postoperative questionnaire to formally assess the experiences and outcomes for 50 patients who underwent free-flaps for LLOM under EA þ Sed. Findings:The mean duration of surgery was 522 min (8.7 h), range 240e875 min. There were no ITU admissions or flap failures. Postoperatively, fifty patients completed a standardised questionnaire about their experiences before the operation, in the anaesthetic room and theatre. 80% were aware of the procedure at least "some of the time". 72.5% patients and 75% respectively, did not have any concerns in the anaesthetic room and theatre. Concerns expressed by the remaining patients were manageable. 97.5% of those patients who recalled their operation reported their overall experience as "comfortable" or "very comfortable". 92% of respondents had undergone previous lower limb surgery under GA ± EA. In this subgroup, 91.3% reported the recovery after EA þ Sed as "quicker" than GA, and 89.4% reported their experience with EA þ Sed as "better". All fifty patients (100%) were "satisfied" or "very satisfied" with their experience and all but one (98%) would recommend this technique to others.Conclusions: Our study showed that despite prolonged duration, the patients' reported experiences and outcomes were excellent when EA þ Sed was used for orthoplastic operations involving free-flaps for LLOM. We recommend EA þ Sed as the anaesthetic technique of choice for such patients.