Current Issue

---

In this week’s issue

• The risk of postoperative endophthalmitis after cataract surgery is significantly greater in eyes with uveitis, corticosteroid use, and immunosuppressant use.
• Children who undergo lensectomy for traumatic cataracts have low likelihood of achieving age-normal BCVA, with nearly 50% requiring a second surgery for visual axis opacification. 
• Fishing-related ocular injuries are declining, however they continue to be a large cause of corneal abrasions, contusions, and intraocular foreign bodies.
• Vitamin B3 supplementation demonstrates a neuro-protective effect on inner retinal nerve fiber layers among patients with normal-tension glaucoma.

https://open.spotify.com/episode/4d7MmwutU83F9zp9xAJvvH?si=iYICvwRCSfmju4Q2PMo0ZQ

Ophthalmology

Balancing inflammation and infection: Endophthalmitis after cataract surgery in immunosuppressed and uveitic eyes

When fighting fire with steroids, could we be fanning the flames of infection? Endophthalmitis is a rare but serious complication after cataract surgery, with its incidence declining over the past century due to improved surgical techniques and prophylactic measures. This study investigates whether systemic immunosuppressive medications, including corticosteroids, increase the risk of acute postoperative endophthalmitis. De-identified data were analyzed from the American Academy of Ophthalmology IRIS® Registry (Rome 2.0) on cataract surgeries performed between 2013 and 2023 to evaluate the association between uveitis and the use of systemic corticosteroids or immunosuppressants with postoperative endophthalmitis within 60 days. Among 9,742,773 cataract surgeries, postoperative endophthalmitis occurred in 0.059% of eyes, with significantly higher rates in eyes with uveitis or systemic corticosteroid/immunosuppressive use; multivariate analysis showed uveitis (OR 7.0), corticosteroid use (OR 2.05), and immunosuppressive therapy (OR 2.37) were all independently associated with increased risk. Systemic corticosteroid and immunosuppressive use, particularly in patients with preexisting uveitis, is associated with an increased risk of postoperative endophthalmitis after cataract surgery. Though the overall incidence remains low, it must be balanced against the risks of discontinuing necessary immunosuppressive therapy.

JAMA Ophthalmology

Visual outcomes & complications following lensectomy for childhood traumatic cataract

I can almost see all the obstacles in my way. The long-term visual and surgical outcomes of lensectomy following pediatric traumatic cataract are not well described. Outcomes may vary based on the severity of injury and whether or not the surgeon decides to leave the patient aphakic at the time of cataract removal. In this prospective cohort study, 75 children with a history of lensectomy following an ocular trauma were assessed for best-corrected visual acuity (BCVA) and ocular complications up to 5 years after surgery. Median age at the time of surgery was 7.4 years. 39 participants were seen at the 5-year follow up visit. Median BCVA for pseudophakic eyes at 5 years was 20/63 and 20/258 for aphakic eyes. Only 6 pseudophakic eyes (21%) and 1 aphakic eye (13%) achieved age-normal VA. 47% of pseudophakic eyes required a secondary surgery for visual axis opacification compared to 13% of aphakic eyes, with greater risk in eyes that did not undergo an anterior vitrectomy (HR 11.4). This data demonstrates the low likelihood of achieving age-normal VA among patients with traumatic cataracts and may help inform parental expectations. 

American Journal of Ophthalmology (AJO)

Hooked on safety: Fishing-associated eye injuries

In recreational fishing, the eye may become the day’s most unfortunate catch. Recreational fishing is a popular US pastime, though its sharp hooks and fast-moving heavy weights pose a significant risk to the eyes if unprotected. This retrospective study analyzed 345 cases from the US National Electronic Injury Surveillance System database from 2005 to 2024 to characterize epidemiologic trends in fishing-associated ocular injuries (FOIs). Throughout the 20-year study period, FOIs have declined (r= -0.481). Most injuries occurred in adult males (83.5%), though children represented a significant proportion (38%). The most common diagnoses were contusions or corneal abrasions (41%), followed by intraocular foreign bodies (19.5%). Fishhooks and lures accounted for 32.5% of injuries, followed by rods and poles (21%) and fishing weights (12%). Severe injuries, such as open globes, hyphema, and lens dislocation, were rare. Most FOI patients were discharged (85.2%), although up to 8% required hospital admission. These findings underscore the importance of protective eye wear. Recognizing how these injuries occur and overall shifts in trends can inform strategies for prevention.

British Journal of Ophthalmology

Can vitamin B3 boost retinal function in normal-tension glaucoma patients?

Turning up NAM for neuroprotection. While lowering intraocular pressure (IOP) remains the cornerstone of glaucoma care, patients with normal-tension glaucoma (NTG) often continue to lose vision despite well-controlled IOP. Previous studies in animal models have shown that nicotinamide (NAM, vitamin B3) supplementation may have a possible neuroprotective effect. This prospective, placebo-controlled crossover trial enrolled 53 NTG participants (IOP ≤18 mm Hg) already on IOP-lowering therapy to assess if oral NAM supplementation enhanced retinal function. Participants received 12 weeks each of placebo and NAM with no washout period in between. Full-field electroretinography revealed significantly greater improvement in the photopic negative response (PhNR) and B-wave amplitudes with NAM versus placebo (+3.12 µV vs +1.00 µV; +2.11 µV vs +0.31 µV) at 12 weeks. Visual field indices remained unchanged over the short study period. No serious adverse events occurred. These findings suggest that NAM supplementation could possibly improve inner retinal function independent of IOP reduction. However, long-term studies are needed to assess durability of its neuroprotective effects.

Eye

Automating eye MRI: MReye-Seg brings standardization to orbital imaging

What if MRI could measure the eye with the precision of a ruler? Currently, MRI-based eye measurements are manual, time-consuming, subjective, and inconsistent, which limit clinical utility. To bridge this gap, researchers developed MReye-Seg, an automated pipeline that transforms standard MRI scans into precise, standardized orbital measurements. The open-source tool creates orbital templates from MRI data, annotates anatomical landmarks, and extracts 38 bilateral volumetric and geometric parameters from optic nerve length to posterior globe shape. MReye-Seg achieved excellent reproducibility (intraclass correlation coefficients >0.8 for 30/38 metrics) and revealed consistent physiological asymmetries between left and right eyes. MReye-Seg simplifies quantification of parameters such as optic nerve sheath volume and globe deformation, which are particularly relevant in conditions such as intracranial hypertension or spaceflight-associated neuro-ocular syndrome, bringing objective precision to ocular MRI.

Ophthalmic Plastic and Reconstructive Surgery

PD-1 immunotherapy for periocular squamous cell carcinoma with perineural spread 

In a dark tunnel of limited options, can PD-1 inhibitor monotherapy offer a glimmer of light? Surgery and radiotherapy are the mainstay treatments for periocular cutaneous squamous cell carcinoma (SCC) with perineural spread into the orbit and skull. However, both aren’t always feasible and come with dangerous risks. This retrospective review included ten patients who had periocular SCC with perineural spread to the orbits and skulls. Those receiving concurrent radiotherapy were excluded. All patients had the ophthalmic branch of the trigeminal nerve involved with many having recurrent disease after surgery, radiation, and chemotherapy. Cemiplimab was used in nine patients with one patient receiving pembrolizumab. Treatments ranged from 2 to 24 months with four patients achieving complete response and six having a partial response. The median follow up was 16 months with all patients showing no evidence of progressive disease at last contact. Based on the results, PD-1 inhibitor monotherapy could be a viable option in the future that could help patients remain in remission and avoid more toxic modalities including radiation and surgery.

The Cornea Donor Study (CDS) - 2013

Is age really just a number? The Cornea Donor Study is a multicenter, double masked, controlled trial initiated in 2000 to provide data to eye banks about the outcomes of donor tissue from various aged donors used for penetrating keratoplasty (PKP). The initial data published in 2008 demonstrated no significant difference in the 12-65 and 66-75 donor age groups, with no significant association between donor age and graft success. The updated analysis reports data after 10 years of follow-up.

Key Points

• There was no significant difference in the 10-year PKP graft success rate for donors aged 12-65 (77%) compared to donors aged 66-75 years old (71%), p=0.11
• Higher donor age was associated with lower graft success after the first 5 years (p<0.001), mostly in the donor aged 72-75 group

The results of this study show no difference in the 10-year PKP graft success rates between donors aged 12-65 and donors aged 66-75. Although the grafts from donors aged 72-75 showed lower success rates, this difference was small (success rates for donors 66-71: 87%, vs 72-75: 85%). The authors concluded that the donor pool should be expanded to donors up to 75 years old.