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February 14, 2024


The most important ophthalmology research updates, delivered directly to you.
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In this week's issue
  • ARMS2/HTRA genotype was associated with faster GA enlargement for eyes with very small GA area in AREDS2 cohort analysis
  • Cross-sectional study of glaucoma patients suggests home lighting is associated with increased home activity
  • Natural language processing of EHR exams was better than ICD-billing codes in identifying lenticular pathology which may broaden research on real-world data
  • RPE sinuosity of foveal B-scans may help diagnosis early age-related macular degeneration

Relationship between ARMS2/HTRA1 genotype and faster geographic atrophy enlargement 

Ophthalmology

Let’s take a look at GENE-ographic atrophy in AMD. Geographic atrophy (GA) is a defining lesion of late age-related macular degeneration (AMD), a progressive condition that is prevalent worldwide. With emerging treatments, understanding genetic risk can play a role in prognosis and therapeutic targets. This study aimed to explore the effects of the ARMS2/HTRA1 genotype to bring clarity to conflicting findings from previous studies. Color fundus photographs of 4203 individuals that were part of the AREDS2 study were examined for GA area at annual visits. Collected data was analyzed using mixed-model regression analysis and proportional hazards regression by ARMS2 genotype. ARMS2 risk alleles were associated with significantly faster GA enlargement (P<0.0001) at rates of 0.224 mm/year, 0.298 mm/year, and 0.317 mm/year for 0 to 2 risk alleles, respectively. In eyes with <1.9 mm^2 area, enlargement was significantly faster with ARMS2 risk alleles (P<0.0001). The ARMS2/HTRA1 genotype was associated with faster GA enlargement, specifically rendering a strong risk factor for faster enlargement in eyes with very small area.

How Illuminating: the role of environmental design in the physical health of the visually impaired

JAMA Ophthalmology

You’ve got to move it, move it. We all know that physical activity is particularly important in maintaining good health; however, those with visual impairments often experience impaired mobility, making moving, even around the home, challenging. While research has been done to investigate the association of environmental factors on fall risks in various populations, little research has been done to investigate environmental factors on physical activity, particularly in older populations with visual impairments. In this cross-sectional study of clinical patients, 153 participants with glaucoma-related visual impairments were followed using a physical activity tracker and GPS for 7 days and a simultaneous environmental survey. Notably, a greater number of steps was significantly associated with better lighting and faster average peak cadence (for every 0.1-log unit increment in average measured home lighting, participants took 5% more daily steps (P= 0.04) and had a 3% faster average daily peak cadence (P = 0.01). Given the positive correlations, further prospective studies could help assess the degree to which considering environment modifications could better assist low-vision patients in more movement important to their overall health.

Natural language processing to identify lens pathology in the EHR

American Journal of Ophthalmology

Big data, bigger possibilities. Many recent ophthalmic studies that use Big Data resources rely upon International Classification of Diseases (ICD) billing codes to identify patients with particular diseases, surgical complications, and assess for disease stability. While ICD billing codes have improved with the transition from ICD-9 to ICD-10 codes, these may be inaccurate, non-specific or just not available. Transitioning from datasets that capture health care claims to newer resources that incorporate clinical data from the electronic health record (EHR) may better identify ocular pathology and enhance the quality of Big Data studies. The purpose of this retrospective database study was to validate an alternative way to identify and characterize ocular pathology using natural language processing (NLP) and compare the performance of a NLP-based algorithm vs ICD billing codes submitted by the clinicians to identify and characterize lenticular pathology. The study team developed an NLP algorithm that searched free-text lens exam data in the EHR and applied the algorithm to 17.5 million lens exam records in the Sight Outcomes Research Collaborative repository. The NLP algorithm correctly identified all lens pathology present in 4104 of the 4314 lens-exam entries (95.1%). Test sensitivity at identifying lens pathology was (0.98 (0.96-0.99)) for NLP vs (0.49 (0.46-0.53)) for billing codes. These study findings suggest that the NLP algorithm identifies and classifies lens abnormalities routinely documented by eye-care professionals with high accuracy. With further validation through larger studies and varied EHRs, it is likely this algorithm could help researchers properly identify and classify ocular pathology, particularly as it pertains to capturing dynamic eye conditions. This would help broaden the scope of feasible research using real-world data.

RPE curvature as a screening metric

IOVS

Introducing a new measure to add to your diagnostic toolkit. Age-related macular degeneration (AMD) is a common cause of vision loss in older adults. Effective clinical management depends on early detection, though accurate diagnosis at earlier stages remains a difficulty for this population. This retrospective cross-sectional study was composed of 434 eyes among four participant groups: patients with early AMD (n = 102) or intermediate AMD (iAMD) (n = 114), patients with normal aging changes (n = 107), and patients with neither AMD nor aging changes (n = 111). Optical coherence tomography B-scans were acquired, and sinuosity, or curvature, of the RPE layer was calculated as the ratio of RPE length to Bruch’s membrane length. Area under the receiver operator characteristic (aROC) was calculated as a functional measure of diagnostic accuracy of the biomarker. RPE sinuosity was significantly greater in AMD eyes vs those without AMD pathology (P < 0.0001); it was also significantly greater for iAMD eyes vs early AMD (P < 0.0001). Diagnostic accuracy of RPE sinuosity in identifying eyes with early or iAMD from eyes without was acceptable (aROC = 0.775), as was accuracy in identifying iAMD eyes from all other groups (aROC = 0.871) or iAMD from early AMD (aROC = 0.737). These results suggest that RPE sinuosity is a promising, quantitative AMD biomarker that could strengthen screening regimen, leading to earlier diagnoses and improved disease management.

Glaucoma

Micropulse transscleral cyclophotocoagulation as potential interim strategy to lower pressure in uncontrolled angle closure glaucoma

Journal of Glaucoma

Transscleral cyclophotocoagulation shooting down high pressure one pulse at a time! Despite the proven efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in reducing intraocular pressure (IOP) in patients with open-angle glaucoma, its effectiveness in individuals with angle closure glaucoma remains uncertain. In this prospective cohort study the authors sought to address this knowledge gap by examining the outcomes of MP-TSCPC in 33 patients diagnosed with primary angle closure glaucoma (PACG), who had uncontrolled IOP despite maximum tolerable medical therapy and patent laser peripheral iridotomies. The authors found that over a 12-month follow-up period, IOP decreased significantly from a baseline of 25.7 ± 5.3 mmHg to 17.9 ± 4.6 mmHg (P ≤ 0.01). Moreover, the number of antiglaucoma medications also significantly decreased, dropping from an average of 4.4 ± 0.8 at baseline to 2.9 ± 1.1 (P ≤ 0.01). While a subset of patients (15.6%) required additional treatment, including subsequent filtering procedures or repeat MP-TSCPC sessions, the findings underscored the efficacy and safety of MP-TSCPC in managing PACG. However, further research with longer-term follow-up is warranted to validate these results and elucidate the optimal role of MP-TSCPC in the comprehensive management of PACG.

Lens Landmarks
Is there a plumber in the house? The TVT study sought to compare the safety and efficacy of tube shunt surgery to trabeculectomy with mitomycin C (MMC) in eyes with prior intraocular surgery. Patients aged 18-85 years old with intraocular pressure (IOP) ≥ 18 mm Hg and ≤ 40 mm Hg on maximum tolerated medical therapy, and who had previously undergone cataract surgery and/or failed filtering glaucoma surgery were randomized into 2 groups: the 350 mm Baerveldt implant group (n = 107) and the trabeculectomy with MMC group (n = 105).

Key Points:
  • Both procedures resulted in similarly sustained IOP reduction through 5 years of follow-up
  • Trabeculectomy group experienced significantly higher failure rate (46.9%) when using more stringent IOP criteria compared to the tube group (29.8%) at 5 years (P = 0.002)
  • Trabeculectomy group underwent higher reoperation for glaucoma (29%) compared to tube group (9%)
TVT is a landmark study in changing practice patterns to expand tube implantation in cases beyond refractory glaucoma. This study demonstrated that tube implantation is more efficacious in lowering IOP in patients who failed previously filtration surgery, rather than undergoing a repeat trabeculectomy.

Question of the Week
A 4-year-old child with inconsistent pediatric medical care presents with a painless, yellow-orange, well-circumscribed, dome-shaped lesion on the iris of the left eye. On examination, the lesion appears vascularized with fine vessels coursing over its surface. Visual acuity is 20/20 in both eyes, and there is no evidence of strabismus or amblyopia. The rest of the anterior and posterior segments are unremarkable. Histology of the lesion shows the image below. Systemic examination reveals no other cutaneous lesions. Mother shares that her child’s left eye has had blood before but spontaneously disappeared.
What is the most likely diagnosis and what additional investigations or management strategies would you consider?

A. Iris melanoma; Sentinel lymph node biopsy
B. Iris cyst; Anterior segment optical coherence tomography (AS-OCT)
C. Iris juvenile xanthogranuloma (JXG); Observation with periodic monitoring
D. Iris hemangioma; Fluorescein angiography
E. Iris metastasis; Systemic workup for primary malignancy


 
Keep scrolling for answer or click here
 

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Quiz Answer: C
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