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February 21, 2024


The most important ophthalmology research updates, delivered directly to you.
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In this week's issue
  • Opioids after ophthalmic surgery can be associated with serious adverse outcomes and counseling patients before prescribing remains important.
  • New study reveals which patient demographics are more likely to require extended inpatient treatment for corneal ulcers.
  • A systematic review summarizes current associations between social determinants of health (SDOH) and dry eye disease in the United States.
  • Chinese patients with Leber hereditary optic neuropathy were more likely to have certain mitochondrial DNA mutations compared to non-East Asians with younger onset and lower optic disc grades indicating favorable prognosis.

Navigating the perils of opioid prescriptions in ophthalmology

Ophthalmology

In the delicate realm of ophthalmic surgery, the use of opioids presents a complex dilemma, balancing appropriate pain management with the alarming risks of addiction and misuse. This retrospective cross sectional analysis of over 1.5 million patients sought to determine the negative effects of prescribing opioids after ophthalmic surgery. Of the patients studied, 20% filled an opioid prescription postoperatively. Filling an opioid prescription postoperatively was associated with increased mortality (Hazard Rate [HR] 1.28), hospitalization (HR 1.51), opioid overdose (HR 7.31), and opioid dependency (HR 13.05, p<0.001 for all) compared to no opioid prescription. Additionally, higher morphine milligram equivalent doses of opioids were associated with higher rates of mortality, hospitalization, abuse and dependence. Ophthalmologists should counsel patients appropriately about the risks of opioids after surgery, and use special judgment or alternative forms of pain control in patients with high risk for opioid misuse.

Sociodemographic determinants of prolonged inpatient stay for corneal ulcer treatment

JAMA Ophthalmology

Who ends up with a site for sore eyes? The incidence of corneal ulcers is over 75,000 cases per year in the United States, giving rise to increased healthcare expenditure and concurrent ocular morbidity. While outpatient management suffices for a majority of cases, many elements contribute to severity and a need for inpatient care. Examining patient data from the Nationwide Inpatient Sample (NIS) between 2015 and 2020, this retrospective cross-sectional study aimed to investigate the impact of variables such as sex, race, medical comorbidities, and insurance status on prolonged inpatient stays for corneal ulcers. 50.2% of individuals analyzed (596/1187) had inpatient stays of <4 days, while 49.5% (588/1187) had longer stays. Prolonged stays were associated with Black patients, age >55, Medicare recipients, diabetes, legal blindness, dementia, alcohol use, and housing insecurity. The results suggest that individuals with characteristics linked to extended inpatient stays may not have been promptly identified in the early stages of their disease progression, potentially because of reduced access to the correct physicians.

Associations between dry eye disease and social determinants of health

American Journal of Ophthalmology

This article is anything but a dry read! Social determinants of health (SDOH) refer to non-medical factors that affect an individual's health and quality of life. The World Health Organization categorizes these into 5 broad categories: neighborhood and built environment, economic stability, social and community context, education, and health care access. Researchers in this study aim to highlight associations between SDOH and dry eye disease (DED) in hopes of expanding methods to quantify SDOH and identifying how these interactions affect patients with DED. Researchers performed a literature review and included 18 studies that reported both cross-sectional and longitudinal associations between SDOH and DED in their analysis. Of the 51 SDOH indicators reported by the studies, “neighborhood and built environment” was the most studied, whereas “access to healthcare” and “degree of education” were among the least studied domains. The majority of the indicators that were studied were associated with poor DED outcomes. While this study may only be able to offer a rudimentary recollection of reported associations between SDOH and DED, it highlights the importance of ongoing efforts to target and address disparities to ensure equitable access to eye care.

Variant and clinical landscape of Leber hereditary optic neuropathy based on 1516 families with mtDNA variants in a tertiary center

British Journal of Ophthalmology

In it for the LHON(g) haul! Leber hereditary optic neuropathy (LHON), a mitochondrial disorder, results in typically painless and central vision loss. This single-center retrospective study includes 1540 diagnostically confirmed LHON patients from 1977 to 2022. Disease history, phenotypic characteristics, and optical coherence tomography (OCT) scans for detailed assessment were collected, along with fundus photography for characterization of the optic disc. A total of 1540 patients were included. Of the 13 pathogenic mtDNA variants detected, m.11778GA and m.3460GA variants were significantly higher in this Chinese LHON population compared to other populations. Although some differences in presentations between males and females were found, they were not statistically significant. A younger-onset of symptoms and low optic disc grade are indicative of a favorable LHON prognosis. Limitations of this study include its retrospective design which may introduce biases, and lack of accounting for possible confounders affecting LHON such as smoking and diet. Moreover, this study is restricted to the Chinese population, limiting its generalizability.

Oculoplastics

Do amblyopia and anisometropia rates vary among early vs. late resolution of congenital nasolacrimal duct obstruction?

Ophthalmic Plastic and Reconstructive Surgery

Is your child’s vision blurry? Congenital nasolacrimal duct obstruction (CNLDO) is a well known risk factor for the development of amblyopia and anisometropia. CNLDO resolution has also been found to be associated with varying rates of amblyopia and anisometropia in older infants. Researchers conducted a retrospective study of 462 patients greater than 9 months of age with early and late spontaneous resolution being compared against an intervention group for rates of amblyopia and anisometropia. Anisometropia was seen in (12/102) 12% of early versus (25/243) 10% of late patients (p = 0.686, 95% CI: –0.059, 0.088), and amblyopia in (4/131) 3% of early versus (14/286) 5% of late patients (p = 0.322, 95% CI: –0.061, 0.018). In patients presenting <24 months without undergoing surgery, spontaneous resolution occurred in 76% between 12 and 24 months (n = 41). To conclude, anisometropia and amblyopia rates may not significantly differ between early and delayed intervention for congenital nasolacrimal duct obstruction in this retrospective cohort presenting beyond 9 months of age to a children’s hospital.

Lens Landmarks

What feels like a brain tumor, acts like a brain tumor, but isn’t a brain tumor? Pseudotumor cerebri! The Idiopathic Intracranial Hypertension Trial (IIHT) sought to determine the effect of acetazolamide in reducing visual loss symptoms after 6 months of treatment, in conjunction with the standard diet and weight loss. Patients with a new diagnosis of IIH by modified Dandy criteria (aged 18-60 years), excluding those with previous IIH or IIH for more than 2 weeks, were randomized to two groups: placebo (n = 79) or acetazolamide (n = 86) for 6 months.

Key Points:
  • Acetazolamide group had greater improvement in perimetric mean deviation (+1.24) versus placebo (+0.71), with P = 0.050
  • Both the acetazolamide group and placebo group improved intracranial pressures and papilledema grade, but the acetazolamide group improved more ( -1.31 versus -0.61, P < 0.001)
  • The acetazolamide group had increased adverse effects (most notably paresthesia and nausea), but no permanent side effects
The IIHT showed that acetazolamide is effective medical therapy, both for lowering intracranial pressure and for treating the visual field defect of moderate idiopathic intracranial hypertension vision loss/papilledema. Normally the limitation to high doses are the side effects, and the side effects seen in this trial were known, such as paresthesia of the extremities, a metallic taste in the mouth, fatigue, and frequent urination. Acetazolamide, as well as weight loss, is the first-line treatment for IIH.

Question of the Week
A 79-year-old male with no significant past ocular history presented with progressively worsening blurry vision in both eyes over a period of several years. He described the vision as cloudy and explained difficulty seeing in poorly lit rooms. He also reported difficulty with watching TV and noted worsening glare and halos with lights, making nighttime driving unsafe. He is currently retired but worked as a metal welder for most of his life. On exam, his IOP was 12 mmHg OD and 15 mmHg OS. Slit lamp examination and H&E staining of the anterior lens capsule are shown below:
Exposure to which of the following types of radiation most likely lead to these findings?
 
A. Ionizing radiation
B. Charged particle radiation
C.  Infrared radiation
D. UV radiation
E. Microwave radiation


 
Keep scrolling for answer or click here
 

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Quiz Answer: C
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