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May 17, 2023


The most important ophthalmology research updates, delivered directly to you.
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In this week's issue
  • Anti-VEGF treats the retina … and the cornea? A new study suggests intravitreal injections improve ocular surface disease.
  • EDI-OCT proves useful for evaluating optic disc drusen to answer the age-old question… is it papilledema or pseudopapilledema?
  • Are cataracts after chemotherapy for retinoblastoma a foregone conclusion? A recent study investigates.
  • The often-dreaded strabismus exam may soon rely on technologies such as smart glasses to help detect angle deviations. 
  • New podcast episode: Click here to listen to our episode highlighting gender equity and women in Ophthalmology with Dr. Grace Sun!

Can serial IVIs treat dry eye?

Ophthalmology

Intravitreal Injections may have a new role in ocular surface therapeutics. Intravitreal injection has become the most common intraocular procedure worldwide, particularly in the context of anti-VEGF therapy for neovascular age-related macular degeneration (nAMD). However, it is believed to cause complications such as corneal epithelium toxicity and dry eye disease. A new study from Stavanger University Hospital in Norway investigated the effects of repeated IVI on the ocular surface and meibomian glands (MG) to determine the possible surface effects of this treatment. 90 patients with nAMD treated with IVI for >4 weeks were included in this single-center study. A range of ocular surface assessments were performed, ranging from tear meniscus height (TMH) and bulbar redness (BR) to corneal staining; upper and lower MG loss was also measured. Treatment with serial IVI was associated with reduced upper and lower MG loss (19.1% vs 25.5 and 17.4% vs 24.5%, respectively), increased TMH (0.36 mm vs 0.32 mm), and lower BR scores (1.32 vs 1.44). This study is the first to suggest that IVI may have therapeutic effects on the ocular surface, given increased tear volume and fewer signs of inflammation in the treatment group.

What imaging modality can we trust to diagnose optic disc drusen?

American Journal of Ophthalmology

ODD findings in one modality may become clearer in another… Optic disc drusen (ODD) are small, calcified deposits found in the prelaminar tissue (superficial to the lamina cribrosa) of the optic nerve head. ODD may cause optic disc elevation, mimicking more sinister conditions such as elevated intracranial pressure, giant cell arteritis, or compressive optic neuropathy. Imaging modalities such as fundus photography, B-scan ultrasonography (US), fundus autofluorescence (FAF), and optical coherence tomography (OCT) can be used to help differentiate ODD from causes of optic disc edema. This study sought to showcase the diagnostic capability of a newer technology called enhanced depth imaging (EDI)-OCT compared to more traditional imaging modalities. The study compared 108 eyes with known ODD and 97 without ODD. All eyes received an ophthalmic exam, imaging by all 4 modalities, and review by 3 masked neuro-ophthalmologists. EDI-OCT had the highest sensitivity and accuracy in detecting ODD discs from non-ODD discs (95%, 97%), followed by FAF (84%, 92%), US (74%, 86%), and fundus photography (38%, 66%). All imaging modalities reported high specificity (>97%) and precision (>93%). EDI-OCT also had the highest examiner confidence (96%). This study confirmed that EDI-OCT is particularly valuable for detection of deeply buried ODD and for ruling out ODD when evaluating causes of apparent optic disc edema.

Risk factors for cataract development in retinoblastoma management

British Journal of Ophthalmology

Are cataracts a blast from the past? Cataracts are a common side effect of radiotherapy for retinoblastoma treatment, and have decreased significantly after a shift to chemotherapy as the preferred treatment modality. As survival rates are now improved for patients with retinoblastoma, treatment goals have placed more emphasis on preserving vision. A retrospective chart review in 184 retinoblastoma eyes of 151 patients from 2017 to 2021 was conducted to evaluate the association of various treatment modalities (intravenous chemotherapy (IVC), intra-arterial chemotherapy (IAC), intravitreal (IvitC) chemotherapy, photocoagulation, and cryotherapy) on cataract development. 16.8% of eyes (31/184) developed cataracts after an average of 27.6 months after treatment. The following factors were associated with increased incidence of the cataract development: high intraocular pressure, endophytic tumor growth pattern, higher melphalan dose per IAC cycle, and higher number of IAC and IvitC cycles. Researchers concluded that toxic melphalan exposure was a core feature in cataract development in patients receiving IAC and IvitC for retinoblastoma. This study is limited by generalizability as this is a retrospective study conducted at a single center in China.

A novel smart glasses system for measuring the angle of deviation in strabismus

Eye

Gone are the old days of strabismus evaluation…maybe! Conventional exam practices for strabismus are heavily operator-dependent and so leave room for human error, thus offering an enticing avenue for technology to augment diagnostic certainty. Newer techniques using video-oculography systems, such as the NeuroSpeed System (NSS) smart glasses, utilize eye-recording smart glasses with automated analyzing capabilities to evaluate patients with strabismus and improve measurement efficacy. This study evaluated strabismic angle deviation testing in 70 individuals, comparing the NSS-based smart glasses with conventional prism alternate cover testing (PACT). Participants were then subdivided into groups based on the type of horizontal deviation (orthodeviation, exodeviation, and esodeviation). The NSS-based system achieved good prediction (or agreement with the PACT) with less than 5 prism diopter (PD) of bias for patients with < 40 PD of horizontal deviation. However, at greater deviation angles, discrepancies in measured esodeviation arose. Method comparison analysis for vertical deviations were not significant due to small sample size. Although PACT remains the gold standard for strabismus evaluation, new technologies such as the NSS smart glasses may soon serve as diagnostic aids in the era of machine-based learning within ophthalmology.

Uveitis

Fluocinolone acetonide injectable intravitreal implant for chronic uveitis

American Journal of Ophthalmology

Uveitis? More like “U-might-need-this”! Uveitis, or intraocular inflammation, is responsible for up to 15% of blindness in the United States. The current gold standard treatment for non-infectious uveitis is steroids, which may be delivered locally or systemically. In 2018, the FDA approved the fluocinolone acetonide 0.18mg implant (FAi) for treatment of chronic uveitis, which lasts for 36 months. This retrospective chart review investigated the safety and efficacy of FAi treatment in patients with chronic uveitis. The study included 103 eyes treated with FAi, each of which had 12 months of follow-up data. All eyes had resolution of active intraocular inflammation and 47.5% of patients had resolution of macular edema by month 6. Nearly a third of patients had ≥ 2-line best corrected visual acuity (BCVA) by 12 months. Adverse events included 6.8% of eyes with IOP rise >10 mm Hg and 20.4% requiring ≥ 2 IOP drops from baseline. Of the 23 phakic eyes included, 30.4% underwent cataract surgery by month 12. While FAi therapy seems to be effective for BCVA improvement and CME resolution at 1 year, its usefulness is limited by steroid-induced glaucoma and cataract development. Long-term data is necessary to determine if these benefits are retained following the 3 year efficacy period of the fluocinolone implant.

Lens Landmarks

How low can you go… with the dose of atropine in myopic children? Following the first ATOM1 study, which showed that 1% atropine could slow myopia progression, the 2012 ATOM2 study sought to determine what dosage provided the most benefit without the cost. In this study, 400 myopic children were randomized to treatment with atropine 0.01% (n=84), atropine 0.1% (n=155), or atropine 0.5% (n=161).

Key Points:
  • There was no clinically significant (although there was statistically significant) difference in the progression of myopia among patients treated with the 3 doses of atropine.
  • Patients treated with atropine 0.01% experienced less visual side effects and minimal atropine-associated adverse events as compared to the 0.1% and 0.5% groups.
Overall, the ATOM2 study is a landmark study because it showed that atropine 0.01% was a safe and efficacious dose in children to decrease the progression of myopia while minimizing the visual side effects seen with higher doses.

Question of the Week
A 74-year old female presents with a 24-hour history of right-sided eye discomfort and conjunctival injection. Her ocular history is notable for pigmentary glaucoma that was managed with combined cataract extraction and trabeculectomy (OD), AMD (OU), and retinal detachment (OS) managed with scleral buckle. On exam, VA is 20/250 (OD) with IOP of 5 mmHg (OD). The right conjunctiva is hyperemic with 3+ cells in the anterior chamber with a small hypopyon. There is a raised, avascular bleb with a small infiltrate visible and positive Seidel test.
Which of the following is a risk factor for this presentation?

A. Elevated IOP
B. Superior location of the filtering bleb
C. Use of intraoperative mitomycin-C
D. Older age


 
Keep scrolling for answer or click here
 

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