Purpose: To investigate the impact of pseudoexfoliation (PEX) syndrome on intraoperative phacoemulsification (PHACO) parameters and assess the economic cost of PHACO surgery for cataracts in patients with and without PEX syndrome. Methods: This was a retrospective quality register study on 5889 patients (6236 eyes) who underwent PHACO cataract surgery in the Eye Clinic, Clinical Hospital Centre Split, Croatia, over a 7-year period (May 2015 to December 2022), in accordance with the Guidelines of the Helsinki Declaration and approval from the Research Ethics Committee of the University Hospital Centre Split, Croatia. Inclusion criteria were patients with either presenile or senile cataract or cataract related to PEX syndrome who undertook PHACO procedure by the same experienced surgeon using the same PHACO device (Infiniti Vision System, Alcon Laboratories, Inc., Fort Worth, TX, USA). Eyes were categorized according to PEX presence- (PEX group) or absence (Group without PEX). The following recorded data about intraoperative PHACO parameters were collected: Cumulative Dissipated Energy (CDE), Ultrasound total time, PHACO time, torsional time, aspiration time, estimated fluid used, and duration of the surgical procedure. In the economic analysis, all PHACO parameters were considered, with a specific focus on the duration of the surgical procedure, costs associated with additional medical materials and devices, complications during surgery, and surgery procedure Diagnosis-Related Group (DRG) codes. Results: A total of 4535 cases were eligible for inclusion in the study, 278 (6.13%) were diagnosed with PEX and 4257 (93.87%) had no PEX. Significantly higher PHACO parameters were observed in the PEX group. Similarly, a statistically significant increase in the values of all PHACO parameters was observed with the increase in nuclear lens density. Intraoperative complications were more frequent in the PEX group. Zonular weakness requiring the use of a capsular tension ring (CTR) and posterior capsular rupture occurred 30 and 13 times more often, respectively, in the PEX group. The expected cost of the PHACO procedure was found to be 1.4 times higher in patients with PEX, compared to those without PEX, for all types of nuclear cataract. Conclusions: All PHACO parameters are significantly higher in patients with PEX. The costs associated with PHACO surgery for cataracts are greater for patients with PEX and are not covered by the present DRG codes, which highlights the need to accordingly adjust the DRGs for PHACO procedures in PEX patients, in order to maintain the quality of healthcare provided for these vulnerable patients.

The authors report a rare case of nonischemic branch retinal vein occlusion and nonischemic hemiretinal vein occlusion in a patient with impaired fibrinolysis. A 61-year-old woman presented to the Department of Ophthalmology, Clinical Hospital Center Split, Croatia, with acute blurring of vision in the right eye (RE) due to branch retinal vein occlusion. Ophthalmologic evaluation revealed a best corrected visual acuity (BCVA) of 0.02 in the RE and of 1.0 in the left eye. Ophthalmoscopy and fluorescein angiography of the RE demonstrated signs of nonischemic branch retinal vein occlusion. She was otherwise healthy and had no other ocular and systemic diseases. She was treated with 3 consecutive intravitreal applications of anti-vascular endothelial growth factor (anti-VEGF; bevacizumab) due to cystoid macular edema with full resolution of the intraretinal fluid and improvement of the BCVA to 0.9. After 8 months, she presented again with acute blurring of vision in the same (right) eye with a BCVA of 0.5. Ophthalmoscopy and fluorescein angiography of the RE indicated nonischemic hemiretinal vein occlusion. She was treated with a single intravitreal application of anti-VEGF (ranibizumab) due to macular edema. Full resolution of the intraretinal fluid and improvement of the BCVA to 0.9 were achieved. A laboratory workup was performed to rule out all known causes of retinal venous occlusive disease, which showed negative results. A molecular analysis showed the gen of thrombophilia – plasminogen activator inhibitor (PAI)-1 4G/5G polymorphism genotype – as the only risk factor for retinal venous occlusive disease in our patient.

Objective To evaluate retino-cortical function in children with Down’s syndrome (DS) and no evident ocular abnormalities beyond mild refractive error, by recording visual evoked potentials (VEP) in response to pattern-reversal stimuli and comparing to those of age-matched healthy controls. Methods and analysis All the children with DS registered at Split-Dalmatia County who met inclusion criteria of no ocular abnormalities and with refraction error between −0.5 and +2.0 D, and their age-matched healthy controls were included in the study (n=36 children, N=72 eyes, for both groups, respectively, with the same age of 9±2 years). Transient VEP was recorded and the waves with a positive peak as a response to a pattern-reversal stimulus, were analysed. The peak P100 latency, defined as the time from the stimulus onset to the main positive peak, and peak to peak amplitudes were measured. Results While P100 wave amplitudes were comparable between two groups (p=0.804), P100 latencies were from 4.3 to 28.5 ms longer in children with DS (p<0.001). Interocular latency difference between a VEP dominant and an inferior eye was pronounced in healthy (1.2 ms (0.2–4.0), but was almost diminished in children with DS (0.3 ms (0.1–0.5), p<0.001). Conclusion Our study has demonstrated that VEP response is divergent in children with DS compared with their age-matched healthy controls, indicating possible structural or functional abnormalities of the visual cortex. As VEP results are helpful in the diagnosis and treatment planning of vision-related disorders, we should reconsider the use of common VEP diagnostic criteria in subpopulation of children with DS.

Purpose: The goal of this research is to investigate the characteristics and surgical techniques for repairing rhegmatogenous retinal detachment (RRD) and their influence on anatomical and functional success of the treatment with a special emphasis on the economic costs and outcome quality-adjusted life years (QALYs) of the procedures. Methods: This retrospective study analyzed data from 151 patients with RRD treated at the Department of Ophthalmology, Clinical Hospital Centre Split, Croatia, in a 3-year period, using one of three surgical techniques: pneumoretinopexy (PR), scleral buckling (SB) or pars plana vitrectomy (PPV), followed-up for at least 6 months. Demographic, pre- and post-operative ophthalmic exam parameters and surgical technique used were collected accordingly. Statistical analysis of the influence of the studied parameters upon anatomical and functional outcomes was performed, as well as health economic analysis on costs and derived utilities/QALYs of these surgical methods. Results: Of all patients, 130 (86%) were successfully operated on, and 21 patients (14%) required another surgical procedure. No statistically significant differences in the anatomical success between the 3 surgical techniques were found. However, the functional outcome (based on the final best corrected visual acuity (BCVA)) differed significantly. Despite improvement in the final BCVA, BCVA ≥ 0.5 was achieved in only 52 (34.4%) patients. The final BCVA showed significant association with the time elapsed from the onset of RRD to the surgical intervention, pre-operative BCVA, macular- and preoperative lens- status and type of surgery. The estimated diagnosis-related group (DRG) cost for day and inpatient surgery was based upon existing DRG cost for PPV, which for PR and SB was calculated accordingly. Based upon the success of the procedure and visual outcome, the overall calculated QALYs for PR and SB appeared to be similar, while the QALYs were lower for PPV. Conclusions: The success rate of treating RRD mostly depends on performing an early surgical procedure (especially in the case of attached macula), identification of all retina tears and, most importantly, choosing the appropriate surgical technique. Decisions on treatment for RRD should also be based upon cost-effective and QALYs-assessed procedures, especially in countries like Croatia, where limited healthcare resources exist. This study shows PR to be efficient and most cost-effective for RRD repairment in appropriate cases.

Background: Open globe injuries (OGI) are the most severe and sight-treating ocular traumas encountered in ophthalmology. The purpose of the study is to analyze the characteristics and prognostic factors of OGI and to evaluate the prognostic value of the Ocular Trauma Score (OTS) in predicting final visual outcome. Methods: A retrospective study analyzing OGI in 56 patients referred to the Eye Clinic, University Hospital Centre Split, Croatia, was conducted between January 2020 and January 2023. The characteristics of OGI and other relevant factors contributing to the final visual outcome were analyzed. The comparison between the final visual outcomes predicted by OTS system and those observed in the study was performed. Non-parametric statistical methods (Wilcoxon, Kruskal-Wallis and chi-square tests) with the Bonferroni correction for multiple comparisons were used in statistical analysis. Results: The average age of patients was 45 years; 48 (86%) were males and 8 (14%) females. Most of the patients (68%) were admitted to the hospital and treated within 6 h after the injury. Most of the injuries (88%) occurred during leisure time and most often were located in zone 2 (46%). Penetrating injuries were the most frequent injury type (52%), while globe rupture was present in 16 (29%) patients. The posterior segment was affected in 27 (48%) patients. In 16 (29%) patients, final BCVA reached ≥ 0.5. The worst final BCVA– NLP was most commonly experienced in patients with globe rupture (38%). Poor final BCVA was statistically significantly associated with worse initial BCVA (P < 0.001), globe rupture (P < 0.001), lower OTS category (P < 0.001), and the presence of RAPD (P < 0.001). The final visual results were comparable with predicted visual outcome by OTS. Conclusions: The study cohort from Croatia showed that the most important factors in the prognosis of final BCVA in OGI were initial BCVA, injury type, RAPD, localization and extent of the wound, and appropriate, timely surgical treatment in specialized institutions with experienced surgeons. Furthermore, our study findings are mostly consistent with those of the international OTS group and support the view that OTS is a reliable predictor of the final visual outcome.

Background and Objectives: To provide, for the first time, statistical data on risk factors for proliferative diabetic retinopathy (PDR) in young-onset type 1 diabetes (T1D) in Croatia, and to develop a predictive health economic model to evaluate the clinical and financial impact of implementing a national diabetic retinopathy (DR) screening. Materials and Methods: A cross-sectional study at University Hospital Split (June 2020–June 2022) analyzed 58 suitable T1D patients out of 562 screened. Patients were classified based on detailed fundus exams and photos into PDR and non-PDR groups. Clinical, demographic, and laboratory data were collected and analyzed using logistic regression. A health economic model was established to project the number of preventable PDR cases and the potential cost savings under various screening scenarios. Results: PDR was found in 47% of patients. Its presence was statistically significantly linked to longer diabetes duration, poor glycemic control, onset before 18 years of age, and irregular eye exams. Irregular ophthalmologic examinations increased the odds of PDR by nearly 30-fold. Health-economic modeling for 10,000 young-onset T1D patients showed that annual screening with 60% uptake could prevent about 1973 PDR cases and save €14.2 million annually. Screening remained cost-effective even with moderate uptake or less frequent intervals. Conclusions: Strict glycemic control and regular eye examinations are critical for preventing PDR in young T1D, and establishing a national screening program would be cost-effective, especially in resource-limited settings like Croatia, where providing appropriate, timely treatment may be challenging.