Copy

September 22, 2021


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

In this week's issue
  • Patients with worse refractive surgery outcomes may be more likely to complete patient reported outcome surveys
  • Smart-phone based parental education reduced 2-year cumulative incidence of childhood myopia by 5%
  • ILM flaps may provide quicker improvement in vision than ILM peels for those with macular holes
  • In vitro, romidepsin and an mTOR inhibitor (AZD-8055) induced apoptosis of uveal melanoma cell lines

How does refractive outcome impact completion of patient reported outcomes? 

Ophthalmology

How many times have you ignored those surveys in your email inbox? In clinical trials, patient reported outcomes (PRO) are useful for assessing outcomes, but in real world practice, the rates of follow-up and completion have been variable. In this retrospective study of LASIK and PRK patients, investigators examined factors that contributed to completion rates of PRO questionnaires at 1 and 3 months post-operatively. Among the 37,043 patients included, 79% attended 1 month follow-up, and 70% of these completed the 1 month PRO questionnaire. 42.5% attended the 3 month follow-up visit, and 66.5% of these completed the 3 month PRO questionnaire. Predictive factors of PRO completion at follow-up included patients who were older, female, underwent PRK, completed the preoperative PRO questionnaire, and had preoperative hyperopic correction (P<0.001 for each). Patients with higher amounts of residual refractive error were more likely to complete PRO questionnaires: each spherical equivalent diopter of refractive error was associated with a 13% and 16% increased odds at 1 month and 3 months, respectively. With each line of postoperative visual acuity worse than 20/16, there was an increased odds ratio for questionnaire completion at 1 month (OR: 1.33) and 3 months (OR: 1.29). This study demonstrates a selective loss to follow-up of postoperative patients in which those with worse objective visual outcomes were significantly more likely to complete PRO questionnaires. Notably, this study illustrates how PRO differs in the environment of real-world studies compared to that of clinical trials where PRO measures originated. 

Effect of a Smartphone-based Parental Education Program on Myopia in Chinese Schoolchildren

JAMA Ophthalmology

Smartphones might actually help improve kids’ vision! Who knew? People with high myopia have an increased risk of various pathologies including cataracts, macular hole, retinal detachment, and macular degeneration. Furthermore, patients who develop myopia before 7 years of age have greater risk of progressing to high myopia. Despite considerable genetic predisposition, optimizing certain environmental factors such as screen time, outdoor activity, and quality sleep have been shown to decrease the likelihood of early-onset myopia. For this study, investigators developed an educational program on the WeChat social media platform, intended to help parents encourage healthy visual behavior habits in ~6 year old schoolchildren without myopia. The parents of 688 children in the intervention group received educational content through WeChat once weekly, while those of 752 children in the control group did not. Of the 1,244 patients who completed final assessment at two years, the cumulative incidence rate of myopia was 106 of 544 (19.5%) in the intervention group and 171 of 700 (24.4%) in the control group (p = 0.04). This study demonstrates the potential for smart-phone based parental education to reduce the risk of early childhood myopia. These results may be culture dependent, so repeat studies outside of China are recommended to investigate generalizability and clinical relevance of the findings.

ILM Flap vs. ILM Peel for Smaller Full-Thickness Macular Holes

American Journal of Ophthalmology

Size matters - for macular holes, at least. This study advocates that the size of the macular hole is a critical factor in deciding the surgical technique for full-thickness macular holes (FTMH). FTMHs can be regarded as small (≤ 250 µm), medium (251–400 µm), or large (> 400 µm). FTMHs threaten visual acuity if left untreated, and peeling the internal limiting membrane (ILM) has become the treatment of choice since its proposal in 1997. Another technique that has been studied is inverting the ILM to create a flap that covers the FTMH, which has been recently reported to have higher surgical success rates. Chou et al. aimed to analyze the early postoperative outcomes of the inverted flap technique vs. ILM peel in small- or medium-sized FTMHs. The investigators conducted a retrospective study which included fifty-five eyes in the flap group and 62 eyes in the peel group. BCVA was significantly better in the flap group than in the peel group at 1 month (20/125 vs. 20/250), 3 months (20/80 vs. 20/125), and 6 months postoperatively (20/80 vs. 20/100) and were comparable at 12 months (both 20/63). Additionally, in the flap group, less foveal gliosis and significantly faster functional recovery and restoration of the outer retinal layers was noted in the early postoperative period. This study suggests that an ILM flap should be considered even for macular holes less than 400 µm, which comprise half of all FTMHs. Notable limitations of this study include the small sample size and loss to follow-up due to the COVID-19 pandemic.

Towards a better treatment for uveal melanoma

IOVS

The saying “less is more” applies to many things in life, but for treating uveal melanoma, perhaps “more” is the way to go! Uveal melanoma is an intraocular malignancy affecting five to six adults per million in the United States. Metastatic disease is quite common and there are currently no effective therapies for metastatic uveal melanoma. Histone deacetylase inhibitors (HDIs) are a class of antitumor agents that have been shown to promote apoptosis in tumor cells. They work by preventing histone deacetylation and promoting a DNA structure that leads to greater expression of genes (yay epigenetics!). The FDA has approved three HDIs as single agents for treating cancer, mainly T-cell lymphoma, yet their role in treating solid malignancies is less clear. In this study, researchers sought to define the role of romidepsin (an HDI) in combination with drugs that target survival pathways on uveal melanoma cell lines. A small drug screen of survival pathway inhibitors (targeting BRD4, ERK, mTOR, PI3K) combined with romidepsin was performed on a panel of uveal melanoma cell lines. Cell death via apoptosis was quantified and transcript/protein changes validated via RNA sequencing and immunoblot. Romidepsin (HDI) in combination with the mTOR inhibitor (AZD-8055) was the most effective combination therapy in inducing apoptosis of uveal melanoma cell lines. These findings represent another potential treatment for uveal melanoma, specifically those harboring the variants of GNAQ or GNA11. While this study was limited to the effects on cell lines, it provides a proof of concept that combination therapy with HDIs and mTOR inhibitors could be used to treat uveal melanoma.

Glaucoma

MIGS vs. Traditional Therapies for Open Angle Glaucoma

JAMA Ophthalmology

Traditional glaucoma treatments are so 2010; are MIGS the way of the future? Open angle glaucoma therapies include lasers, eye drops, and filtering surgeries, and minimally invasive glaucoma surgeries (MIGS), which cause limited disruption to conjunctiva or sclera. This meta-analysis summarizes data from randomized clinical trials of MIGS for open-angle glaucoma by investigating the outcomes of glaucoma treatment by MIGS with cataract extraction alone, other MIGS, traditional glaucoma surgery, laser trabeculoplasty, or medical therapy. They measured primary outcomes including the need for IOP-lowering drops at short term (<6 months), medium-term (6-18 months), and long-term (>18 months) follow-up. This study showed that compared with cataract surgery alone, the addition of a trabecular bypass stent (Hydrus microstent or iStent) safely improved glaucoma control without use of medication. The Hydrus conferred a benefit of approximately 2.0 mm Hg decline in intraocular pressure (Hydrus 95% CI, 1.4-1.8 relative risk [RR], 1.6; iStent RR, 1.4; 95% CI, 1.2-1.6). However, the iStent’s IOP reduction was not sustained. MIGS stand as a promising treatment in the field of glaucoma with an emphasis on reduced medication burden and increased quality of life (QOL).

Global Health

Global Refractive Error Patterns - a Disparity?

BMC Public Health

“Just a glasses issue” is something we often hear in ophthalmology. While true refractive errors are a correctable condition, refractive error causes significant visual impairment leading to limitations in employment, education, and general satisfaction globally, even more so than many common eye diseases. Le et al. used disability adjusted life years (DALYs) in the Global Burden of Disease 2019 study to determine effects of gender, socioeconomic status, access to electricity, and urban exposure in relation to incidence of refractive error. Ultimately, crude DALY rates, when adjusted for global population and life expectancy increase, show stability in disease burden from 1990 to 2019. Increased disease burden was noted in countries with lower socioeconomic status, with only 3.7 eye doctors per million people in lower income countries. The highest prevalence of myopia and rate of blindness from refractive error were noted in the young population of East and Southeast Asia (80-90%). The results of this study highlight populations in need of more attentive visual care: women older than 65 and citizens of countries with low SES. As expected, limited access to resources including healthcare and electricity play an important role in disease burden.

Question of the Week
A 44-year-old male presents to ophthalmology clinic with concern for dry eye and blurry vision for the last three months. In addition, the patient has had blisters on the arms and mouth. Exam is significant for the external photo shown below, mild superficial punctate keratopathy, blisters on the arm that easily rupture, and some mucosal scabbing around the lips and on the oral mucosa. Ocular motility is not significantly impeded. The patient was recently seen in dermatology clinic and a punch biopsy taken from a lesion on the arm revealed IgG deposits in a lattice like pattern with basal cells still attached to the basal membrane.
What is the most likely cause of this patient’s ocular exam finding?
A.     Pemphigus vulgaris
B.     Bullous pemphigoid
C.     Pterygium
D.     Sequela of Steven-Johnson Syndrome

 
Keep scrolling for answer or click here
 

Helpful Links

Quiz Answer: A
Quiz Answer Explained
Twitter Twitter
Website Website
Share with a friend Share with a friend
Copyright © 2021 The Lens Newsletter LLC, All rights reserved.