August 25, 2021

The most important ophthalmology research updates, delivered directly to you.

Sneak Peek: The Lens Artificial Intelligence Newsletter
Preview the first issue of Lens AI, and stay up to date on cutting edge developments regarding the use of Artificial Intelligence to diagnose and treat eye disease.

The Lens Pod: This week, we speak with Dr. Ben Young, host of the Eyes For Ears Podcast, who shares with us what medical students should know before their first retina clinic and OR. Find the episode on Spotify, Apple Podcasts, or our website. Happy listening!

Risks of Anti-VEGF Injections 1: Risk Factor for Intraretinal Fluid?

American Journal of Ophthalmology

There are many different kinds of shots: COVID-19 vaccine, Fireball, Avastin. Only one of them can potentially cause intraretinal fluid development after injection (that we know of). Last week, we summarized new benefits of anti-VEGF injections, but no benefit comes without risk. Although it is known that intraretinal fluid (IRF) in neovascular AMD is associated with poor visual outcomes, few studies investigated the risk factors associated with IRF development during anti-VEGF treatment. In this retrospective cohort study by Cho et al., 425 treatment-naive patients with neovascular AMD were treated with anti-VEGF injections and monitored for a period of 24 months. IRF occurred in 40.2% (171/425 eyes) of all participants, and that larger areas of choroidal neovascularization, the presence of IRF at baseline, and the presence of fibrovascular pigment epithelial detachment were all associated with an increased risk of IRF development. This information should guide clinicians in their management of patients with neovascular AMD, utilizing these risk factors to judiciously employ anti-VEGF treatment when weighed against possible development of intraretinal fluid.

Risks of Anti-VEGF Injections 2: Endophthalmitis in Operating Room vs. Clinic

JAMA Ophthalmology

Intravitreal injections (IVI) are one of the most widely performed ophthalmologic procedures worldwide. Among the medications delivered by IVI, anti-vascular endothelial growth factor (anti-VEGF) monoclonal antibodies play a particularly important role in the management of angiogenic diseases such as exudative age-related macular degeneration, proliferative diabetic retinopathy, and diabetic macular edema. Due to the chronic, progressive nature of these conditions, patients often receive anti-VEGF IVIs on a recurring basis, raising concern for iatrogenic endophthalmitis. To mitigate this risk, ophthalmologists in Europe and resource-limited countries tend to perform IVIs in the operating room (OR). Meanwhile, United States ophthalmologists prefer clinic-based IVI for improved time- and cost-efficiency. In a meta-analysis of 31 studies and 1,275,815 injections, investigators compared the rate of endophthalmitis following anti-VEGF IVI in the clinic and OR setting. The study found no increase ✅in the odds of endophthalmitis for clinic- compared to OR-based IVI (odds ratio 3.06, 95% CI 0.07-139.75, P = 0.57). Furthermore, there was no significant difference in the pooled rate of endophthalmitis between the office (0.03%, 95% CI 0.03-0.04) and OR (0.02%, 95% CI 0.01-0.04) setting. These results suggest that injection setting does not influence the rate of iatrogenic endophthalmitis to a significant degree. However, due to the strong influence of regional preferences on practice patterns, direct comparison between clinic- and OR-based IVI within resource-limited countries was limited in this study.

Congratulations 🎉🎉 to Abhi Bheemidi of Case Western Reserve University, the winner of our Volk 60D Slit Lamp Lens Giveaway! All subscribers have a chance to win, but tune into our social media (Twitter; Instagram) and subscribe to The Lens Pod (details at the top of the email) to increase your chance to win a 78D and 90D Volk Lens! 👀

May E-FORCSE Be With You: Opioid Use in Ophthalmology

Ophthalmology

Remember sitting in D.A.R.E. and hearing, “Don’t do drugs kids!” Well, what if they’re prescribed? As one of the most pressing public health issues plaguing the world today, the opioid epidemic is one that affects virtually every field of medicine, including Ophthalmology. While managing a patient’s peri- and post-operative pain, it is a physician’s duty to be mindful of the serious implications of opioid prescription, such as the development of new persistent opioid use. Potential risk factors contributing to new persistent opioid use (filling an opioid prescription 4-180 days post-op) were identified by a retrospective cohort analysis of 327,379 opioid-naïve patients who underwent incisional ophthalmic surgery. Researchers identified that initial opioid prescription fill perioperatively (OR: 6.21, 95%CI: 5.57-6.91; p<0.001) and prescription size ≥ 150 morphine mg equivalents (OR: 1.87, 95%CI: 1.58-2.22; p<0.001) had the greatest impacts on new persistent opioid use in previously opioid-naïve patients. Additional risk factors included age between 50 and 59 years, female sex, Black race, and lower household income, among others. These findings allow for surgeons to understand the need to minimize opioid prescription whenever feasible, as doing so will have a large effect on decreasing persistent opioid use following ophthalmic surgery.

The ocular surface microbiome and tear proteome

IOVS

We can’t see them, but there’s a whole ecosystem of microbes on and around our eyes helping to protect our vision! There is no doubt that the human microbiome plays an important role in health and disease. From the gut to the lungs and beyond, there has been an explosion of research aimed at understanding the microbial communities that live on or within us. The 2007 Human Microbiome Project characterized microbiomes of 5 different body sites (skin, GI tract, oral cavity, nasal passages, urogenital tract), however missing from that short list is the surface of the eyes. Lid and conjunctival swabs were obtained from 20 participants. Bacterial community composition was determined using whole-metagenome shotgun sequencing and the tear proteome was characterized using mass spectrometry. The researchers performed gene ontology and functional analysis to link the tear proteome to the ocular microbiome. A total of 229 taxa were identified from the ocular surface with Actinobacteria and Proteobacteria being the most abundant phyla. Analysis revealed important links between the ocular microbiome and production of proteins important in the antimicrobial response including lactoferrin, lipocalin-1, lysozyme, mucins and IgA. Several molecules were also found to correlate with fatty acid binding, heme biosynthesis, and sensory perception – all of which have effects on vision function. The presence of a fully functional ocular microbiome is critical for vision as dysbiosis of these communities can lead to development of eye disease. This study sheds light on a previously underexplored area of microbiome research that can have a significant impact on how we diagnose, treat, and prevent ocular diseases moving forward.

Glaucoma

IOP Measurement: Intraoperator, Interoperator, and Interdevice Reliability

Journal of Glaucoma

Under pressure: Choosing the best device for IOP measurement. This cross- sectional study investigates the intraoperator and interoperator reliability of intraocular pressure (IOP) measurement using two devices: Goldmanns tonometry and rebound tonometry (RT) with the ic100 tonometer. Three studies were conducted on patients with established glaucoma, suspected glaucoma, and no glaucoma, to measure intraoperator reliability (measurements by 1 operator), interoperator reliability (3 different operators), and interdevice reliability (3 measurements across devices). Interoperator reliability: there was a 70% lower within-subject variance of RT compared to Goldmann’s. Interoperator reliability: there was no difference in measurements between operators. Interdevice reliability: there was no difference in mean IOP between devices. The RT’s superior measurement variability and comparable good interoperator and interdevice reproducibility suggests that it may have benefits over Goldmann tonometry, the current gold standard.

Global Health

When and where: will your ocular trauma care differ by location?

British Journal of Ophthalmology

With an incidence of 3.5 people per 100,000, open globe injuries (OGI) are managed differently due to clinical variation. A survey containing questions regarding institutional OGI management practices was distributed via email to ophthalmic trauma specialists from 42 institutions worldwide. Thirty three institutions with high trauma volumes were included. Most (75.8) utilized pre-operative antibiotics. 39.4% operated as soon as possible while others operated the first morning following presentation. US centers were more likely to perform enucleation. Variation in the use of imaging revealed that accessibility was a major factor in OCT acquisition. Variations exist in perioperative antibiotic use for the management of OGI, and the efficacy of the different antibiotic regimens currently in use is an area for potential future research. Timing of OGI repair and/or foreign body removal is another area of discordance amongst experts and literature. Although literature suggests there is increased morbidity associated with delaying surgical repair, many institutions wait until the next morning to perform surgery for OGIs that present in the middle of the night. On the flip side, out of hours repair is also associated with increased morbidity. US institutions are more likely to prioritize urgent OGI repair even if it means performing surgery outside of typical work hours.

End of Month Quiz

1. The PANORAMA study, recently published in JAMA Ophthalmology, generated new evidence that afilbercept has benefits for the severity and progression of which disease?
A. Non-proliferative Diabetic Retinopathy
B. Age-related Macular Degeneration
C. Retinopathy of Prematurity
D. Neovascular Glaucoma

2. Which predictive factor was associated with faster spherical equivalent progression and axial length elongation in patients with myopia treated with atropine?
A. Parental myopia status
B. Hours of outdoor activity per day
C. Younger age of treatment
D. Older age of treatment

3. Zhou et al. recently reported in the American Journal of Ophthalmology that what measurement was significantly higher in active Grave's Ophthalmopathy than in inactive disease?
A. Corneal thickness
B. Coefficient variant of corneal endothelial cell area
C. Corneal endothelial cell density
D. Average corneal cell area

4. True or false: analysis of patients diagnosed with retinoblastoma in 2017 internationally suggests no predominance of diagnosis in males or females.
A. True
B. False

Keep scrolling for answer or click here

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Quiz Answers: 1A, 2C, 3B, 4B
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