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February 28, 2024


The most important ophthalmology research updates, delivered directly to you.
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In this week's issue
  • MicroShunt and trabeculectomy in glaucoma treatment both provided significant reductions in IOP and medication use after 2 years, however trabeculectomy had greater surgical success rates.
  • Cross-sectional analysis reveals vision impairment was associated with depression, anxiety, and social isolation, emphasizing the direct connection between vision and psychosocial outcomes.
  • Complex cases of central serous chorioretinopathy (CSC) were associated with older age, male sex, bilateral involvement, and thick sclera.
  • A newly developed algorithm based on SD-OCT can define genotype-phenotype interactions in X-linked retinoschisis, with cyst cavity volume significantly correlated with missense RS1 protein mutations.

MicroShunt vs. trabeculectomy in primary open-angle glaucoma treatment

Ophthalmology

Tube vs. Trab? The great debate! The Cairns-type trabeculectomy is the standard surgery for reducing intraocular pressure (IOP) in glaucoma, especially in advanced cases, despite its potential complications. Although micro-invasive glaucoma surgery (MIGS), including the MicroShunt, is less efficacious, it has been shown to have fewer side effects, making it a viable option for patients with less aggressive therapeutic goals. A recent prospective, randomized, multicenter, non-inferiority trial compared the MicroShunt with trabeculectomy in patients with uncontrolled open-angle glaucoma. This study included 527 subjects, with 395 receiving the MicroShunt and 132 undergoing trabeculectomy. Surgical success rates, defined as >20% reduction in IOP with no increase in glaucoma medications, were 50.6% in the MicroShunt group and 64.4% in the trabeculectomy group (P=0.005). In addition, the study demonstrated that while the MicroShunt had a lower rate of hypotony compared to trabeculectomy, it was associated with a higher need for postoperative interventions such as bleb needling and revision. The two-year results of this trial showed that trabeculectomy had greater IOP reduction and surgical success rates than the MicroShunt, which is consistent with results observed after 1 year. However, several factors, including surgeon experience, patient demographics, and postoperative scarring, can influence outcomes, highlighting the need for individualized treatment decisions based on the risks and benefits of each procedure.

The psychosocial impact of visual impairment in adults

JAMA Ophthalmology

Can poor vision portend a poor mood? It is well known that psychosocial conditions can contribute to overall morbidity. A group of researchers wanted to evaluate vision’s impact on these psychosocial conditions, which may ultimately contribute to overall morbidity. They conducted a cross-sectional study on a nationally representative sample of 2,822 Medicare beneficiaries aged 65 years and older from a sample of over 26 million individuals to assess for a correlation between vision impairment (VI) and depression, anxiety, and social isolation. They found that those with objectively quantified VI exhibited higher odds for depressive symptoms (OR 1.81; 95% CI, 1.26-2.58), anxiety symptoms (OR 1.74; 95% CI, 1.12-2.67), and social isolation (OR 2.01; 95% CI, 1.05-3.87). Individuals with self-reported VI had greater odds for depressive symptoms (OR 2.37; 95% CI, 1.44-3.88) and anxiety symptoms (OR 2.10; 95% CI, 1.09-4.05). These findings highlight the link between vision and psychosocial wellbeing. Understanding this impact can spread greater awareness to providers when considering patients as a whole.

Scleral thickness variance: Deciphering simple and complex forms of central serous chorioretinopathy

American Journal of Ophthalmology

Thicker sclera, tougher problems: Unraveling the mysteries of simple versus complex central serous chorioretinopathy. Central serous chorioretinopathy (CSC) is characterized by fluid accumulation under the retina, causing visual impairment. Its cause is unclear, though stress and corticosteroid are suspected contributors. Additionally, it is hypothesized that the severity of CSC may be influenced by scleral factors. A recent retrospective, cross-sectional study classified 217 eyes with CSC as simple or complex based on multimodal imaging and analyzing various clinical and anatomical factors. Multivariable analysis revealed that complex CSC was associated with older age (OR 1.054, p<0.001), male gender (OR 10.445, p<0.001), bilateral presentation (OR 7.641, p<0.001), and mean scleral thickness (OR 1.022, p<0.001). These factors, particularly scleral thickness, were strongly predictive of complex CSC. Understanding this relationship is important for ophthalmologists and could pave the way for scleral measurements to become a standard in crafting targeted treatments for CSC.

Enhancing clinic technologies to provide prognostic information for X-linked retinoschisis

IOVS

It's the future I can see, that's so OCT. X-linked retinoschisis is an inherited retinal dystrophy leading to vision loss. Patients can have different mutations in the gene RS1 which codes for a protein providing structural support to the retina. Depending on the mutation, there can be varying levels of disease severity, necessitating different treatment plans. The authors of a recent study created an algorithm to determine genotype-phenotype correlations using spectral-domain optical coherence tomography (SD-OCT) and electroretinogram (ERG) data from 37 patients with 27 unique RS1 mutations. Cyst cavity volume (CCV) on SD-OCT significantly correlated with the location of missense mutations in the protein (e.g. surface hydrophobic area of protein). Amplitude of scotopic 3.0 ERG a-waves and b-waves also significantly correlated with the degree of alteration the mutation had on the protein's structure. The information produced from this algorithm may provide patients and physicians with prognostic insight and help plan future treatments. One benefit of this approach is that it relies on technologies already used in the ophthalmology clinic.

Cornea

One-year outcomes of processed amniotic fluid drops after photorefractive keratectomy

Cornea

Can amniotic fluid ease the pain after photorefractive keratectomy (PRK)? For those who are not a candidate for LASIK, an alternative procedure is PRK. Although PRK has its advantages, there are a few disadvantages, including increased post-operative pain and prolonged visual recovery. Processed amniotic fluid (pAF) has inherent regenerative properties, and has been proven to benefit corneal burns, ulcers, and wounds. However, little is known about the efficacy and long-term safety of pAF after PRK. A recent double-masked, placebo-controlled clinical trial randomized 61 participants to receive either placebo or pAF drops 4 times a day for 1 week after PRK in addition to routine postoperative medications, and followed them for 1 year. At 1-month post-PRK, the pAF group showed greater uncorrected visual acuity and less corneal irregularity compared to the placebo group (p=0.007, p=0.05). However, no difference was seen at 3, 6, and 12-month follow-up, as well as for corneal staining score at any time point. Overall, pAF is safe and may contribute to early visual and topographical improvement.

Lens Landmarks

Atropine can make you hot as a hare and red as a beet! But can also reduce myopia progression? High myopia is associated with excessive eyeball growth leading to sight-threatening complications down the road. Although concentration-dependent responses in myopia control were evident with higher-concentration atropine eye drops (ATOM study), the role of low-concentration atropine in myopia control was uncertain. This double-blinded, randomized control trial evaluated the efficacy and safety of atropine eye drops at 0.05%, 0.025%, and 0.01% compared with placebo over a 1-year period. 438 children, ages 4 to 12, with myopia of at least −1.0 diopter (D) and astigmatism of −2.5 D or less were included.

Key Points:
  • A significant concentration-dependent response on myopia control (spherical equivalent and axial length change) was observed in all atropine concentrations at 1 year 
  • Changes in accommodation amplitude and pupil size also followed a concentration-dependent response in all groups
  • Visual acuity and vision-related quality of life were not affected
This landmark study demonstrated that low-concentration atropine eye drops reduced both spherical equivalent progression and axial length elongation along a concentration-dependent response, with 0.05% atropine eye drops being the most effective dose in reducing myopia progression.

Question of the Week
A 70-year-old male patient presents with decreased vision in the left eye that was gradual in onset. He denies any recent falls, trauma, associated ocular pain, or photophobia. Past ocular and surgical history are non-significant. Visual acuity was hand motion with an intraocular pressure of 65 mmHg. Moderately open angle was seen with gonioscopy. Slit lamp findings are shown below.
Which of the following would have most likely caused these findings on slit lamp examination?

A.      Fuch’s heterochromic iridocyclitis
B.      Pseudoexfoliation glaucoma
C.      Neovascular glaucoma
D.      Pigmentary glaucoma


 
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Quiz Answer: B
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