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In this week’s issue

• Among ophthalmic transfers to a level 1 trauma center, less than half had accurate diagnoses, while pretransfer evaluation by an eye care provider was associated with higher diagnostic accuracy and need for intervention.
• Although IOP has been proven as a continuous risk factor when treating glaucoma, the historic cutoff of 22 mmHg is used by many clinicians as an inflection point for initiating or escalating IOP-lowering therapies.
• Longer outdoor daylight exposure was associated with higher IOP and increased incidence of primary open-angle glaucoma.
• Targeting the fission protein Drp1 in RPEs demonstrates promise in preserving mitochondrial structure and consequently mitigating the vision-threatening effects of neovascular AMD. 

Spotify Link:

https://open.spotify.com/episode/6rpLaLuuQDHKw65ABEGPL4?si=CxurYLIfQX6pDZRDbCJ8hw 

Ophthalmology

Efficacy of ophthalmic transfers to an academic level 1 trauma hospital

Was it worth the trip? Ophthalmic conditions remain rare in the emergency department, but ophthalmic transfers to academic trauma centers are increasingly common. However, such transfers may strain resources and add burden to patients and the healthcare system if they do not result in any intervention or hospital admission. This retrospective cross-sectional study included 685 patients who were transferred to a level 1 trauma center from a US hospital system over one year. The main outcome measures characterized were accuracy of transfer diagnoses and rate of procedural interventions or admission after transfer. Less than half of transfer diagnoses were accurate (48.9%), and half (50.2%) of all transferred patients were discharged without admission or intervention within one month. Only 6.1% of patients received an in-person evaluation by an eye care provider before transfer, but those who did were significantly more likely to have an accurate diagnosis (90.5% vs 66.3%) and to require admission or intervention (90.5% vs 46.8%). Ultimately, these findings show that many ophthalmic transfers may not be clinically necessary, and that a pre-transfer evaluation or screening tools may improve diagnostic accuracy.

JAMA Ophthalmology

How IOP shapes glaucoma treatment decisions

Does glaucoma care still draw the line at 22? Intraocular pressure (IOP) is the primary modifiable risk factor for glaucoma progression. Contemporary evidence supports treating IOP as a continuous risk factor rather than a fixed cutoff. However, the long-standing teaching that IOPs ≥22 mm Hg are “abnormal” may still influence how clinicians make treatment decisions. In this large retrospective multicenter cohort study of patients with glaucoma across seven US academic centers, investigators examined how IOP levels affected real-world treatment patterns. Although rates of IOP-lowering treatment increased gradually with rising IOP, clinicians were disproportionately more likely to initiate or escalate therapy at IOPs ≥22 mm Hg, revealing a clear inflection point at this level. Mixed-effects logistic regression confirmed significantly higher odds of treatment initiation at 22 mm Hg compared with lower IOP values. Together, these findings suggest that while clinicians generally recognize IOP as a continuous risk factor, historical thresholds may still shape glaucoma management decisions. This underscores the potential value of clinical decision support tools to reduce cognitive bias and promote more nuanced care.

American Journal of Ophthalmology (AJO)

Excessive sunlight may increase risk of open angle glaucoma

Can fun in the sun be too much for glaucoma? Sunlight has been theorized to have a relationship with glaucoma, but this study provides significant power by utilizing a cohort of over 67,000 UK Biobank participants to directly examine the long-term link between daylight duration and POAG incidence. This fills a critical gap where previous research primarily focused on other types such as exfoliation glaucoma. Researchers found that increased outdoor daylight exposure is associated with a higher risk of developing the condition though it was not statistically significant. For each additional hour of average annual exposure, the hazard ratio for POAG incidence was 1.10. Interestingly, the risk was significant in males but not females, suggesting a possible sex-based interaction. The study also revealed that prolonged annual exposure is significantly linked to elevated intraocular pressure, which may mediate the increased POAG risk. These findings highlight a need for further investigation into a modifiable potential contributor to the development of POAG.

Journal of Glaucoma

Physical activity and glaucoma: Can moving more protect vision?

Can physical activity reduce the risk of primary open-angle glaucoma (POAG)? Using data from the National Institutes of Health All of Us Research Program, this observational study evaluated 266 adults with POAG and 7,954 controls, all of whom had Fitbit and electronic health record data. Participants with glaucoma had slightly lower step counts than controls (6,673 vs. 6,891 steps/day). However, after adjusting for demographics, comorbidities, and beta-blocker use, no significant association between physical activity and odds of glaucoma was observed. Sub-analyses by age (>40 and >65 years) also showed no meaningful differences. The authors conclude that, unlike other chronic diseases, daily physical activity does not appear to influence POAG diagnosis. While device-measured activity provides objective insight, limitations include small sample size and potential residual confounding factors.

Journal: BMJ Open Ophthalmology

Enhancing AI-based diabetic retinopathy diagnosis

Diabetic retinopathy (DR) is a leading cause of preventable vision loss, and timely screening is essential to reduce disease progression. Although deep learning (DL) algorithms have demonstrated strong performance in DR detection, their clinical deployment is often limited by variability in retinal images acquired from different fundus cameras, particularly portable devices used in community screening programs. In this study, researchers evaluated a style-adaptation deep learning framework designed to improve model robustness across heterogeneous imaging systems. Retinal images captured using both portable and standard fundus cameras were harmonized using a Style-Consistent Retinal Image Transformation Network prior to classification. The adapted model achieved approximately 79% diagnostic accuracy, with high agreement with expert graders (κ ≈ 0.89), while reducing false positives compared to non-adapted models. These results demonstrate that camera-independent AI systems can maintain reliable DR detection across diverse clinical environments. Such adaptability is critical for scaling AI-driven screening programs, particularly in low-resource settings, and may help bridge gaps in access to early ophthalmic care.

The Diabetes Control and Complications Trial - 1995

Is putting off the sweets worth the reward? The DCCT sought to understand whether tighter glycemic control would lead to better outcomes in diabetic retinopathy (DR). Prior to this study, there were limited cutoffs and guidance as to what Hemoglobin A1c levels and what type of insulin regimens were best for managing patients with Type 1 Diabetes. The DCCT randomized 1441 patients with Type 1 Diabetes to “intensive” versus “conventional” glucose control, and measured both the rate of retinopathy development (cohort 1) and retinopathy progression (cohort 2).

Key Points

• “Intensive” glycemic control led to a 78.5% risk reduction in the development of DR and a 64.5% risk reduction in the progression of DR in those who had mild-moderate NPDR
• Across both treatment groups and both cohorts, lowering A1c led to significant reductions in the likelihood of DR development (10% A1c reduction led to 45% relative risk reduction) and DR progression (10% A1c reduction led to 43% relative risk reduction)

The DCCT (and the similar themed UKPDS for Type 2 Diabetes) illustrated across large sample sizes and randomized controlled trials the importance of tight glycemic control. Together, these two studies created a target goal for Hgb A1c < 7.0% for patients to avoid long-term ophthalmic complications from diabetes.