Current Issue

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In this week’s issue

• A cross-cohort study identified hs-CRP, an inflammatory factor, as a risk factor to both retinal artery occlusion and ischemic stroke
• Subfoveal, unifocal, and fast-growing lesions are at the highest risk of vision loss in those with geographic atrophy, one of the major causes of irreversible vision loss in AMD.
• Toric Intraocular Lens (TIOL) implantation may offers superior astigmatism correction in individuals with high degrees of astigmatism and those with against-the-rule astigmatism.

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Ophthalmology
Investigating the factors involved in visual loss in geographic atrophy

The fast and the foveal – what risk factors correlated with lesion growth rate and vision loss in geographic atrophy? Geographic atrophy (GA) is a major cause of irreversible vision loss in age-related macular degeneration (AMD), and has a variable clinical presentation and complex progression patterns. Further research is necessary to fulfill the need of identifying effective treatments of GA, as its pathophysiology is not fully understood and there are currently limited treatment options. The treatment options currently available require continuous and frequent intravitreal injections. This study conducted a retrospective analysis of 2006 study eyes with bilateral GA from two phase 3 clinical trials and a prospective observational study,  to assess the correlation of lesion growth rate and baseline factors (including foveal involvement and focality) on visual loss. After a 2 year follow-up, main outcome measures included correlations of baseline BCVA, GA area, and growth rate with change in BCVA, and time to ≥5, ≥10, and ≥15-letter loss by foveal involvement or focality. The study found that BCVA and GA area at baseline did not correlate with BCVA changes, and GA growth rate had a weak correlation with BCVA loss. Eyes with subfoveal and unifocal lesions in the two highest GA growth rate quartiles experienced the most rapid decline in visual acuity, and approximately 75%, 50%, and 25% of study eyes lost ≥5, ≥10, and ≥15 letters by two years, respectively. These findings suggest that patients with subfoveal, unifocal, and fast-growing lesions are at the highest risk of vision loss, These findings may help guide treatment strategies that target inhibiting GA progression.

JAMA Ophthalmology

FSAK vs TIOL: Which is more effective for astigmatism correction in FLACS?

When it comes to correcting astigmatism, does one procedure really outshine the other? Astigmatism correction during femtosecond laser-assisted cataract surgery (FLACS) is crucial for optimal visual outcomes. Two popular techniques, Femtosecond Laser-Assisted Astigmatic Keratotomy (FSAK) and Toric Intraocular Lens (TIOL) implantation, are often compared. However, it remains to be determined which procedure offers superior astigmatism correction capabilities. This study sought to evaluate the effectiveness of both methods for astigmatism correction in FLACS. This randomized clinical trial compared FSAK and TIOL implantation in patients with mild to moderate astigmatism undergoing FLACS, with a sample size of 196 participants. TIOL implantation showed superior astigmatism correction for preoperative astigmatism >1.5 D and ATR (against-the-rule) astigmatism compared to FSAK, although both techniques demonstrated similar improvements in visual acuity and refractive astigmatism when analyzing all study participants. Both FSAK and TIOL implantation are effective for astigmatism correction in FLACS, but TIOL implantation may offer a better solution for higher degrees of astigmatism, particularly ATR.

American Journal of Ophthalmology

The Ocular Pressure Adjusting Pump safely and effectively reduces intraocular pressure (IOP) in patients with normal-pressure glaucoma

Get pumped – the Ocular Pressure Adjusting Pump is transforming glaucoma treatment! For years, the mainstay of normal-tension glaucoma treatment has involved a combination of pharmacological and surgical IOP-lowering methods. Historically, less invasive methods of IOP reduction have failed to lower IOP at night, which is when most patients experience their maximal pressures. The Ocular Pressure Adjusting Pump is a novel, wearable device designed to decrease IOP in patients with normal-pressure glaucoma, any time of day. This prospective, randomized control trial investigates the safety and effectiveness of the Ocular Pressure Adjusting pump in reducing IOP in patients (n = 186 eyes) with normal-tension glaucoma, by having them wear the device at night for 1 year. At 52 weeks, nocturnal IOP was reduced by a mean of 8.0 mmHg, which equated to a 39.1% IOP reduction from the study baseline of 20.4 ± 2.5 mmHg. This was found to be statistically significant. At week 52, 88.3% of study subjects achieved IOP reduction of ≥20%, as compared to 1.7% of their control group counterparts. No concerning adverse effects were reported during this study. The results of this study indicate that the Ocular Adjusting Pump is both an effective and safe tool for day and nighttime IOP reduction in normal-tension glaucoma. As the first FDA-approved normal-tension glaucoma treatment that is non-invasive and effectively reduces IOP around the clock, it will surely revolutionize glaucoma treatment.

British Journal of Ophthalmology

Can inflammatory markers predict the risk of retinal artery occlusion?

Do inflammation and ischemia go hand in hand? Retinal artery occlusion (RAO) is an acute ischemic that can cause severe visual loss. Ischemic stroke (IS) similarly is an ischemic event affecting the cerebral vasculature and is the leading cause of disability and second leading cause of mortality in those older than 60 years of age. Inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) have been associated with ischemic strokes, however, their role in the pathophysiology of RAO remains unclear. In this cross-cohort study, 459,188 participants from the UK Biobank (of which there were 136 cases of incident RAO and 3206 cases of incident IS events over a median of 12.2 years) and 338 participants from the Chinese Retinal Artery Occlusion Study were included. For the UK Biobank, cox proportional hazard models were used whereas in the Chinese cohort utilized logistic regression to study the association of hs-CRP with incident RAO and IS. In the UK Biobank, higher hs-CRP levels were associated with increased risk of RAO (HR: 1.34, p=0.04 in the UK Biobank and OR: 1.43, p=0.001 in the Chinese cohort) and IS (HR: 1.24, p<0.001 in the UK Biobank and OR: 1.13, p=0.013 in the Chinese cohort). RAO patients with higher hs-CRP levels were more likely to also have IS. This study suggests that individuals with higher inflammatory markers are at a higher risk of developing both RAO and IS. This information offers a paradigm shift that could assist in guiding risk-based screening and prevention of these conditions. 

Ophthalmic Plastic and Reconstructive Surgery

Wondering if that pricey silicone gel is worth the splurge? 

Turns out, your wallet may thank you more than your blepharoplasty scar! Scarring is a common concern after eyelid surgery, but there is no consensus on the best topical treatment. While silicone gel has shown efficacy in scar management on other parts of the body, its effectiveness on the eyelids’ thin, delicate skin remains uncertain. This study, the first prospective, randomized, double-blinded trial comparing silicone gel with petrolatum ointment for eyelid scars, provides valuable insights for post-operative care. Ninety-six patients (n = 192 eyelids) undergoing bilateral upper eyelid blepharoplasty were enrolled, with one eyelid treated with silicone gel and the other with petrolatum placebo. Clinical and patient-reported assessments were conducted over six months. No statistically significant differences were found between the treatments in physician-graded outcomes (erythema, elevation, pigmentation) or patient-reported measures (satisfaction, itching, pain, firmness) at any time point. Both physicians and patients showed no preference for silicone-treated versus placebo-treated eyelids. Overall, this study suggests that silicone gel may not offer significant benefits over more affordable petrolatum ointment for upper eyelid scars. Clinicians may want to prioritize more cost-effective options for managing scars on the uniquely thin eyelid skin.

Collaborative Initial Glaucoma Treatment Study (CIGTS)

Medication or Surgery: Which path to tread in open-angle glaucoma? In the Collaborative Initial Glaucoma Treatment Study (CIGTS), a total of 607 patients with newly diagnosed open-angle glaucoma were randomized into either medication or surgery (trabeculectomy with and without 5-fluorouracil). Over a period of up to five years, visual field loss (primary outcome), in addition to visual acuity (VA), intraocular pressure, and the development of cataracts were monitored.

Key Points:

• Visual field outcomes were not significantly different based on initial treatment
• Surgical patients experienced a heightened risk of VA loss in the early phases, though by year four, VA was almost equal between the two groups
• The initial surgical intervention group maintained a lower IOP (14-15 mmHg) compared to the initial medical group (17-18 mmHg)
• There was a higher rate of patients who underwent cataract removal in the surgery group

Overall, the CIGTS stands as a landmark study because it offered valuable insight into the long-term outcomes of both medical and surgical initial treatment for open-angle glaucoma. Prior to this study, there were uncertainties regarding the comparative effects of these treatments. The CIGTS elucidated that visual field loss can be minimized for both treatment methods, while also highlighting potential risks associated with each treatment, such as the higher rate of cataract removal in surgically treated patients.