Current Issue

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In this week’s issue

• Blue light-filtering IOLs increase the risk of depressive disorders compared to standard clear IOLs
• A manual marking-assisted approach is noninferior to digital guidance systems with respect to capsulorhexis accuracy and centration
• Predictors for glaucoma progression in African ancestry patients include high IOP, myopia, and absence of hypertension
• Triglycerides may serve as a biomarker to help risk-stratify and guide management in patients with TED
• A predictive model using easily accessible variables helps evaluate risk of uveitis in patients with juvenile idiopathic arthritis

https://open.spotify.com/episode/2IV8G6qk3rQw9JbWRjClNk?si=H3k-O3pMQuShQ9-Pq2cKXw 

Ophthalmology

Depression risk in blue light deprivation after cataract surgery

Turns out, seeing blue keeps you from feeling blue. Intraocular lens implants (IOLs), used to replace the native crystalline lens during cataract surgery, are now available in a dizzying array of makes and models. In particular, multifocal and extended depth of focus (EDOF) IOLs, allow for sharp vision at a greater range of distances compared to the standard, monofocal IOL. Others like the toric lenses can correct a patient’s astigmatism. Still, others have been designed to filter out wavelengths of light toward the higher-frequency end of the visible spectrum. The stated advantages of such “blue light-filtering” (BLF) IOLs range from mitigating uncomfortable glare to reducing the progression of age-related macular degeneration. And while there is some evidence to support the idea that light with a wavelength around 440 nm can increase oxidative stress on photoreceptors, and therefore filtering this light may be beneficial, recent work published by a team of South Korean researchers suggests the effects of lenses doing just that may not be entirely rosy. They compiled medical records from 14,010 individuals who elected to receive BLF IOLs in both eyes during cataract surgery then compared the rate of depression in this cohort with that observed in an age- and sex-matched cohort of equal size. The risk of depressive disorders increased by 1.16-fold (P<0.001) among individuals with BLF IOLs relative to those with clear IOLs after adjusting for systemic comorbidities and follow-up duration. While this effect may sound modest, on a population level, it translates to thousands of additional individuals developing depressive symptoms unnecessarily. These results suggest additional pre-operative counseling may be warranted for patients considering BLF IOLs on the increased risk of depression associated with these lenses.

JAMA Ophthalmology

Manual marking-assisted vs. digital guidance-assisted capsulorhexis

Steady hands rival digital plans. Capsulorhexis is a critical initial step in phacoemulsification cataract surgery. The size and centration of the capsulorhexis are closely tied to intraocular lens (IOL) stability and postoperative complication rates. While digital image projection systems have been introduced to improve the accuracy and centration of the capsulorhexis, their adoption has been limited due to high costs and logistical barriers. In this single-center, randomized clinical trial, the authors evaluated a manual marking-assisted capsulorhexis (MMAC) technique that modifies a standard intraocular injection needle into a lens caliper. The primary outcome was deviation from a target capsulorhexis diameter of 5.3 mm. Among 156 patients randomized to either the MMAC or digital guidance-assisted capsulorhexis (DGAC) groups, the median deviation of the horizontal capsulorhexis diameter was 0.22 mm for MMAC and 0.27 mm for DGAC. 96.2% of cases in the MMAC group and 88.5% in the DGAC group achieved an ideal capsulorhexis, defined as a centered, round opening measuring 5.0–5.5 mm in diameter that fully overlaps with the IOL optic edge. This study demonstrates that a manual marking-assisted approach is noninferior to digital guidance systems with respect to capsulorhexis accuracy, centration, and postoperative visual and IOL stability outcomes.

American Journal of Ophthalmology (AJO)

Predictors of glaucoma conversion in an African ancestry cohort

Glaucoma may start quietly but identifying who’s at risk should be loud and clear. Primary open-angle glaucoma (POAG) is a major cause of irreversible vision loss and disproportionately affects individuals of African ancestry. Predicting which glaucoma suspects will progress to POAG is critical for early intervention, however, data on progression risk in populations of African ancestry have been limited. This study aimed to help fill that gap by identifying risk factors for conversion in this high-risk group. In a prospective case-control study, 330 African ancestry glaucoma suspects from the larger POAAGG cohort (Primary Open-Angle African American Glaucoma Genetics study) were followed for a median of 6.7 years, using standardized optic nerve and visual field criteria to confirm progression. Nearly 14% of suspects converted to POAG during follow-up. Elevated intraocular pressure (≥21 mmHg), absence of hypertension, and myopia (≤-0.5D) were independently associated with higher conversion risk (HR: 2.49, 2.40, and 2.35, respectively). These findings suggest that glaucoma suspects of African ancestry with these risk factors warrant closer monitoring and highlight the need for more targeted screening strategies.

British Journal of Ophthalmology 

Are triglycerides an overlooked clue to thyroid eye disease?

Sometimes, a lipid panel can tell a story that extends well beyond cardiovascular risk. Thyroid eye disease (TED), also known as Graves’ orbitopathy, can manifest with proptosis, diplopia, and in severe cases, compressive optic neuropathy. Prior studies have suggested possible links between dyslipidemia and TED, but have focused on cholesterol subfractions (LDL, HDL) and statin use. In this multicenter, retrospective study of 330 patients in South Korea with TED, all of whom had elevated thyroid autoantibodies and no prior systemic steroid treatment, researchers evaluated the relationship between various lipid parameters, including triglycerides, and disease activity and severity. Higher triglyceride levels were independently associated with both TED activity (OR=1.005) and severity (OR=1.004), and this relationship persisted in analyses excluding statin users. ROC curves identified optimal triglyceride cutoffs of 104 mg/dl for active TED and 108 mg/dL for severe TED. These findings suggest that triglycerides may serve as a simple, accessible biomarker to help risk-stratify and guide management in patients with TED. 

Pediatric Rheumatology

Machine learning model predicts uveitis risk in JIA

A flare to beware. Uveitis is a significant complication of juvenile idiopathic arthritis (JIA) and is estimated to develop in up to 30% of JIA cases. This retrospective, single-center study developed a machine learning model to predict the risk of developing uveitis in JIA. The model contains stepwise logistic regression and least absolute shrinkage and selection operator (LASSO) regression. The model indicated JIA patients who developed uveitis were younger at the age of arthritis onset (7.27 ± 3.27 vs. 8.26 ± 4.06 years, p=0.048). Oligoarticular JIA was the most common subtype (46.58%) among patients with uveitis. Furthermore, ANA positivity was significantly higher in the non-uveitis group (61.64% vs. 8.84%, p<0.001), and ANA was not significantly correlated with the activity or duration of JIA uveitis. Due to the range of communication skills and development within the pediatric population, there can be a delay in identifying visual changes which can delay uveitis diagnosis. This model highlights easily accessible clinical variables that may assist in risk-stratification of uveitis risk in patients with JIA, helping provide earlier diagnosis and treatment.

JAMA Ophthalmology

Predicting RNFL thickness from OHTS optic disc photographs

Glaucoma often creeps in silently. Patients with elevated intraocular pressure may go years without functional loss, while structural damage mounts. Early identification of those at highest risk for transitioning from ocular hypertension to frank glaucoma has remained a key challenge in ophthalmic practice. This multi-decade study leveraged the long-running Ocular Hypertension Treatment Study (OHTS) cohort, involving 3,272 eyes from 1,636 participants, and applied a novel “machine-to-machine” deep learning algorithm trained on 66,714 optic disc photographs to predict mean retinal nerve fiber layer (RNFL) thickness. The model found that every 10 µm thinner in predicted RNFL at baseline was associated with ~83% higher hazard of conversion to primary open-angle glaucoma (POAG) (HR 1.83), and each 1 µm/year faster predicted RNFL thinning carried a ~6-fold increased risk (HR 6.01).These results suggest that AI-derived RNFL estimates from standard fundus photos can serve as quantitative, objective risk markers which can potentially transform how we stratify glaucoma risk, monitor progression, and decide on early intervention.

Cryotherapy for ROP (CRYO-ROP)

Colder than the tip of the eyesburg. The multicenter Trial of Cryotherapy for Retinopathy of Prematurity was developed in the 1980s to provide a more evidence-based approach to the treatment of retinopathy of prematurity. More specifically, the study sought to determine the value and outcomes of peripheral ablative treatment (specifically cryotherapy) for the treatment of ROP.

Key Points

• Treated eyes had a 49.3% reduction in “unfavorable” outcomes based on masked grading of fundus photographs at 3 and 12 months (21.8% in treated, 43.0% in untreated)
• In the 10 year follow-up, it was noted that anatomic outcomes were better than functional outcomes, meaning outcomes based on imaging may overestimate the impact of treatment

Overall, the CRYO-ROP was a landmark study for both the screening and treatment of ROP, even if the specific treatment has become a secondary one in the time since. The main findings of this study showcase a decreased incidence of blindness and retinal detachment, improved visual acuity outcomes, and improved structural outcomes in eyes treated with cryotherapy. A second-generation study, the ET-ROP, studied laser photocoagulation as ablative treatment, which has now become the paradigm for ROP management.