Publications by authors named "Nir Gomel"

9 Publications

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Teleophthalmology Screening for Early Detection of Ocular Diseases in Underserved Populations in Israel.

Telemed J E Health 2021 May 17. Epub 2021 May 17.

Division of Ophthalmology, Tel-Aviv Medical Center, Tel Aviv, Israel.

The purpose of this study was to investigate the feasibility and effectiveness of an innovative telemedicine community-based intervention to increase detection of previously undiagnosed ocular diseases in high-risk populations in Israel. A team comprising an ocular technician, a project manager, and a driver was sent to underserved areas in Israel. Patient demographics, ocular, and medical information were recorded. Visual acuity (VA), intraocular pressure and fundus photographs were obtained. The data were transferred to the Ophthalmology Reading Center in Tel-Aviv Medical Center, where it was interpreted by an ophthalmologist. A letter was sent to the patients indicating examination results. It instructed them to return for a follow-up examination if indicated. A total of 124 individuals underwent telemedicine remote screening examinations in 10 locations. The mean age was 79.9 7.2 years, with female predominance of 67%. The major pathologies detected were (1) reduction in VA >6/12 in at least one eye ( = 48, 38.7%); (2) glaucoma suspicion in the optic disk ( = 18, 14.5%); (3) ocular hypertension >21 mmHg ( = 15, 12.1%); (4) age-related macular degeneration (AMD;  = 15, 12.1%); (5) diabetic retinopathy ( = 6, 4.8%); (6) visually significant cataract ( = 6, 4.8%); and (7) other pathologies ( = 11, 8.9%); 97.7% of the patients reported high satisfaction rates (they were satisfied or very satisfied from the project model). Our pilot telemedicine screening project effectively detected ocular diseases in underserved areas in Israel and helped improve access to eye care. This project has the potential of reaching a national level, allow for early diagnosis, and prevent vision loss and blindness in underserved areas.
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May 2021

Lag Time between Onset of First Symptom and Treatment of Retinoblastoma: An International Collaborative Study of 692 Patients from 10 Countries.

Cancers (Basel) 2021 Apr 19;13(8). Epub 2021 Apr 19.

Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA.

Background: The relationship between lag time and outcomes in retinoblastoma (RB) is unclear. In this study, we aimed to study the effect of lag time between onset of symptoms and diagnosis of retinoblastoma (RB) in countries based on their national-income and analyse its effect on the outcomes.

Methods: We performed a prospective study of 692 patients from 11 RB centres in 10 countries from 1 January 2019 to 31 December 2019.

Results: The following factors were significantly different among different countries based on national-income level: age at diagnosis of RB ( = 0.001), distance from home to nearest primary healthcare centre ( = 0.03) and mean lag time between detection of first symptom to visit to RB treatment centre ( = 0.0007). After adjusting for country income, increased lag time between onset of symptoms and diagnosis of RB was associated with higher chances of an advanced tumour at presentation ( < 0.001), higher chances of high-risk histopathology features ( = 0.003), regional lymph node metastasis ( < 0.001), systemic metastasis ( < 0.001) and death ( < 0.001).

Conclusions: There is a significant difference in the lag time between onset of signs and symptoms and referral to an RB treatment centre among countries based on national income resulting in significant differences in the presenting features and clinical outcomes.
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April 2021

Low-dose Bleomycin Injections for Orbital Lymphatic and Lymphatic-Venous Malformations: A Multicentric Case Series Study.

Ophthalmic Plast Reconstr Surg 2021 Jul-Aug 01;37(4):361-365

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: Orbital lymphatic malformations (LM) are associated with ocular morbidity and facial disfigurement. Surgery is challenging and may not be effective. We describe the outcome of bleomycin injections for venous LM and lymphatic-venous malformation (LVM) malformations of the orbit in 5 tertiary referral centers between January 2010 and December 2018.

Methods: Multicenter retrospective case series, 5 oculoplastic referral centers: Sheba and Rabin Medical Centers, Israel; Mulago Hospital, Uganda; Sri Sankaradeva Nethralaya, India; and Clinique Ophtalmologique de Tunis, Tunisia. All patients diagnosed with orbital LM/LVM were assigned to successive (range 1-6) intralesional 5 international units bleomycin injections. They all underwent complete ophthalmic and orbital evaluations, orbital imaging, and ancillary testing as needed. Clinical photographs were assessed pre- and posttreatment along with objective assessments of clinical improvement. Additional injections were provided in cases of incomplete response.

Results: A total of 21 patients (17 women, mean ± standard deviation age 18 ± 13 years, range 2-48 years) underwent bleomycin injections. The mean injection dose was 12 ± 10 international units in 1-3 injections. There was a dramatic improvement in lesion size, appearance, proptosis, and ocular motility in 20/21 patients (95%) after a mean follow-up of 18 months. Visual acuity slightly improved after treatment (20/50-20/30; P = 0.076). No side effects were noted after bleomycin injections.

Conclusions: Bleomycin injections for LM/LVM of the orbit are effective; local or systemic side effects were not seen in this series. To the best of our knowledge, this is the largest reported series of this treatment.
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July 2021

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries.

Br J Ophthalmol 2020 Sep 15. Epub 2020 Sep 15.

Pediatric Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain.

Background: The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

Methods: A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

Results: Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

Conclusions: Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.
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September 2020

Predictors of traumatic eye injuries at high-risk for ophthalmic complications in children.

Eur J Pediatr 2021 Jan 8;180(1):177-185. Epub 2020 Jul 8.

Pediatric Emergency Medicine Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Eye injuries are important cause of ocular morbidity in children. There is lack of data regarding predictors for high-risk injuries that will result in ophthalmic complications. Most cases are managed by the emergency department (ED) physicians without immediate ophthalmologist evaluation. Our aim was to identify predictors for ophthalmological complications and to imply indications for early ophthalmologic consultation in the ED. A retrospective chart review of 834 patients ages 0-18 years who presented to the emergency department at Tel Aviv Medical Center between 2015 and 2018 following traumatic eye injuries was performed. All cases which later needed ophthalmological care were considered as high-risk for ophthalmic complications. An increased rate of eye injury was revealed over the years, but high-risk injury rate was stable. High-velocity mechanism, sport injury, orbital, anterior chamber, and retinal involvement were all significantly more common in the high-risk group compared to the low risk group. Only 10 patients, which represent 1.2% of all the patients, had decreased visual acuity on the last follow up, with significantly more injuries of high-velocity mechanism and anterior chamber involvement, in comparison to patients with normal visual acuity on the last follow up.Conclusion: High-velocity mechanism by itself, even with normal visual acuity and eye examination by the ED physician, should prompt to consider an urgent ophthalmologist consult. What is Known: •Traumatic eye injuries are an important cause of ocular morbidity in children. • Most injuries can be handled by a trained ED physician, but there are indications for an urgent ophthalmologist consultation. • It is crucial to discriminate between low and high-risk ocular injuries. What is New: • High-velocity mechanisms stand out as the most likely risk factor for final impaired visual acuity. • Normal visual acuity on presentation is not reassuring. • We recommend urgent ophthalmologist consultation in cases of high-velocity injury, even if visual acuity is preserved at presentation.
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January 2021

The effect of the glycemic control on the aqueous humor glucose levels in diabetic patients undergoing elective cataract surgery.

Eur J Ophthalmol 2021 Mar 12;31(2):415-421. Epub 2020 Mar 12.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: Aqueous humor glucose levels play a role in the anterior segment disorders' pathophysiology, mainly in diabetics. Our purpose was to evaluate the ratio of aqueous humor glucose levels to blood glucose levels in diabetics and to evaluate the correlation between this ratio and blood glycated hemoglobin (HbA1c) levels.

Methods: This prospective study was performed in Sheba Medical Center during 2016-2018. The study included type 2 diabetic patients admitted for elective cataract surgery. Blood glucose levels were measured immediately before surgery. HbA1c was obtained within 3 months preoperatively. At the beginning of surgery, 0.05-0.1 mL aqueous humor was drawn. Main outcome measures were aqueous humor glucose/blood glucose ratio and the correlation between HbA1c and aqueous humor glucose/blood glucose ratio.

Results: Thirty-seven patients (mean age 75.2 ± 11.2 years) were recruited. The average aqueous humor glucose/blood glucose ratio was 0.69 ± 0.20. A significant positive correlation was found between aqueous humor and blood glucose levels, Pearson coefficient constant R = 0.63 (p < 0.01), and specifically stronger among older patients R = 0.89 (p < 0.01), females R = 0.74 (p < 0.01), patients with short-term disease (<10 years) R = 0.80 (p < 0.01), and patients treated with oral anti-diabetic treatment R = 0.74 (p < 0.01). A significant strong positive correlation was found between HbA1c levels and aqueous humor glucose/blood glucose ratio R = 0.62 (p < 0.01), and specifically stronger among older patients R = 0.82 (p < 0.01), males R = 0.70 (p < 0.01), patients with prolonged disease (⩾10 years) R = 0.540 (p < 0.05), and patients treated with oral anti-diabetic treatment R = 0.62 (p < 0.01).

Conclusion: A significant strong correlation was found between aqueous humor glucose levels and blood glucose levels. Poor glycemic control was strongly correlated with an increased ratio, reflecting an increased anterior chamber's glucose permeability. Older age group was found to have stronger correlation of poor glycemic control with this ratio.
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March 2021

Global Retinoblastoma Presentation and Analysis by National Income Level.

JAMA Oncol 2020 05;6(5):685-695

Imam Hussein Cancer Center, Karbala, Iraq.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, And Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes And Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions And Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.
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May 2020

SNP variations in IL10, TNFα and TNFAIP3 genes in patients with dry eye syndrome and Sjogren's syndrome.

J Inflamm (Lond) 2019 18;16. Epub 2019 Mar 18.

2Department of Ophthalmology, Hadassah-Hebrew University Medical Center, POB 12000, 91120 Jerusalem, Israel.

Background: Cytokines are known to be key players in dry eye syndrome (DES) and Sjogren's syndrome (SS) pathogenesis. In this study we compared single nucleotide polymorphism (SNP) variations in genes encoding cytokine levels among SS and DES patients in Israel.

Methods: We recruited 180 subjects, 82 with SS and 98 with DES. Using a candidate gene approach and allele-specific PCR technique for genotyping, proportions of risk alleles in Tumor Necrosis Factor α (TNFα) (rs1800629), IinterLeukin-10 (IL-10) (rs1800896) and TNFAIP3 (rs2230926) SNPs were compared between study groups.

Results: Allelic distribution was found very similar to Caucasian (CEU - Utah residents with Northern and Western European roots) population distributions in these SNPs. While none of the SNPs' variants were significantly associated with SS or DES in a recessive model, in an additive model the TNFα G risk allele was found higher among SS patients compared to DES (Homozygote-G: 84.2% vs. 70.8%; Heterozygote: 26.9% vs. 11.2%, respectively,  = 0.02). After adjustment for age, gender and ethnicity, these variants weren't associated with SS. Genetic scoring reveals that SS patients are more likely to present variants of all three SNPs than DES subjects.

Conclusions: This is the first study evaluating these SNP variations among both patients with DES and patients with SS. We found the allelic distribution in each SNP to be very similar to that found in healthy Caucasian populations presented in the HapMap project. We found the TNFα allele significantly associated with DES for homozygotes, and associated with SS for heterozygotes in the additive model.
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March 2019

Predictive factors for efficacy and safety in refractive surgery for myopia.

PLoS One 2018 14;13(12):e0208608. Epub 2018 Dec 14.

Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Purpose: To evaluate the predictive factors for safety and efficacy in laser refractive surgery for myopia.

Setting: A singular refractive surgery center, at a University-affiliated tertiary medical center.

Design: Retrospective cohort study.

Methods: Study population-A total 8,775 eyes having laser refractive laser procedures for myopia (in4,623 patients). Observation procedures-Using a prospective database of refractive procedures performed over the span of 13 years, variables such as gender, age, type of surgery, date of surgery, pre-operative corneal thickness and Spherical Equivalent (SEQ) were evaluated. Main outcome measures-Proportion of patients with Safety index higher than 0.85 and Efficacy index higher than 0.80.

Results: 91.9% and 86.0% of all evaluated eyes were above the safety and efficacy cut-off levels, respectively. Younger age was significantly correlated with safety and efficacy indices above the cut-off levels (p<0.001). Male gender was significantly correlated with efficacy above the cut-off level (p<0.001). Myopic eyes with lower SEQ were associated with both safety (p = 0.002) and efficacy (p<0.001) indices above the cut-offs. The surgical procedure was found to significantly affect the outcome only using univariate analysis: Safety was higher in Photorefractive Keratectomy (PRK), while Efficacy was higher in Laser Assisted In Situ Keratomileusis (LASIK) (p<0.001, respectively) but no difference was found using multivariate analysis. Safety index above the cut-off level increased over the years (p<0.001).

Conclusions: Efficacy in refractive surgery for myopia is correlated with younger age, male gender and low myopia. Safety is correlated with younger age, low myopia and increases over the years. Multivariate analysis found no differences between PRK and LASIK regarding safety and efficacy.
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May 2019