In this week’s issue

• Open angle glaucoma in an elderly Australian population is about 6%, with age, pseudoexfoliation, myopia, and elevated IOP being the strongest risk factors.
• Iridotrabecular contact (ITC), especially in the nasal sector, is associated with an almost 5-fold increase in progression toward acute angle closure. 
• Implantable collamer lenses (ICL) may be preferred over keratorefractive lenticule extraction (KLEx) in high myopes with anisometropia. 
• In children with autism spectrum disorder, amblyopia and strabismus amplify functional difficulties compared to those with normal vision.

Ophthalmology

Fifteen-year incidence of open-angle glaucoma

What is the incidence of open-angle glaucoma in an older population? Open-angle glaucoma (OAG) is a leading cause of irreversible blindness worldwide, but long-term incidence data remain limited. This population-based cohort study from the Blue Mountains Eye Study assessed the 15-year cumulative incidence of OAG in 3,654 patients from an older Australian population. Among participants without OAG at baseline, 140 developed incident disease over 15 years, including 116 definite and 24 probable cases. The age-standardized 15-year incidence was 5.67% (95% CI, 4.65-6.68) for definite and probable OAG and 4.72% (95% CI, 3.79-5.64) for definite OAG. After adjusting for competing risks, incidence remained similar at 5.57% and 4.81%, respectively. Age, pseudoexfoliation, myopia of at least 3 diopters, and higher intraocular pressure were strong risk factors for incident OAG. Ultimately, these findings provide valuable long-term epidemiologic data to identify high-risk patients and plan future glaucoma care needs in aging populations.

JAMA Ophthalmology 

Iridotrabecular contact and progression in angle closure suspects

A little too close for comfort. Identifying which primary angle closure suspect (PACS) eyes will progress to primary angle closure (PAC) remains a challenge. Current anterior segment OCT (AS-OCT) derived biometric measurements can predict progression, but they are time consuming and not widely accessible in routine practice. Thus a more readily visible qualitative feature on AS-OCT, the iridotrabecular contact (ITC), may be more helpful for risk stratification. However, its association with progression to PAC is unclear. In this retrospective cohort study, using data from the Zhongshan Angle Closure Prevention (ZAP) trial, 825 untreated PACS eyes were analyzed over 72 months to evaluate whether ITC could predict progression to PAC. ITC presence in the nasal sector had a 4.68-fold higher risk of angle closure progression. Longer ITC length in the nasal or superior sectors also have an increased risk for progression. Each incremental increase in ITC length (per 250 μm) was associated with an increase in progression risk, suggesting that ITC may function as a continuous marker of disease severity. Qualitative assessment of ITC on AS-OCT may offer an alternative for identifying high risk PACS eyes. Incorporating ITC into routine evaluation may improve risk stratification and guide closer monitoring or earlier intervention in patients most at risk of angle closure progression.

American Journal of Ophthalmology (AJO)

Outcomes of implantable collamer lens vs. KLEx for myopia correction

In anisometropia, one size doesn’t fit both eyes. Anisometropia, or significant differences in refractive error between eyes, can disrupt binocular vision and lead to visual fatigue. Keratorefractive lenticule extraction (KLEx) and implantable collamer lenses (ICL) are widely used refractive procedures with strong safety and efficacy profiles, with ICL favored for treating high myopia of greater than 12 diopters. The combination of these two techniques may be a solution for patients with significant anisometropia. This retrospective comparative case series included 50 eyes from 25 myopic patients (ICL in the more myopic eye; KLEx surgery in the contralateral eye) with 7-year follow-up, evaluating visual acuity, refractive stability, wavefront aberrations, retinal image quality, and patient-reported visual disturbances. At 7 years, both KLEx and ICL had high levels of safety and refractive stability. ICL demonstrated superior visual outcomes with lower intraocular scattering and a higher Strehl ratio, while KLEx showed slightly lower higher-order aberrations. These findings suggest that while both procedures are effective, ICL may offer improved visual quality and stability in high myopia, and a combined approach in anisometropic patients can provide a tailored treatment approach.

JAAPOS

When vision compounds the social picture in ASD

Sometimes the eyes may be adding more to the story than we realize. Children with autism spectrum disorder (ASD) have higher rates of ophthalmic conditions such as amblyopia and strabismus, but it has been unclear whether these visual disorders meaningfully shape autism-related behaviors. That question matters for pediatric ophthalmologists because social development, visual attention, and adaptive behavior are closely intertwined. This study explored whether binocular vision disorders might worsen functional challenges already present in ASD. Investigators compared 43 children with ASD ages 3-17 years, including 14 with amblyopia and/or strabismus and 29 with normal eye exams aside from corrected refractive error, using ophthalmic exams plus VABS-III, SRS-2, and RBS-R questionnaires. Children with ASD and comorbid amblyopia/strabismus had lower adaptive behavior composite and socialization scores, with additional weaknesses in written communication, community living, interpersonal relationships, and play/leisure, additionally they also showed greater insistence on sameness, while SRS-2 scores did not differ between groups. These findings suggest that vision disorders may amplify real-world functional difficulties in ASD, raising the possibility that identifying and treating amblyopia or strabismus could have benefits beyond visual outcomes alone.  

Amblyopia Treatment Study (ATS) – Patching vs. Correction

Usually a quick patch doesn’t solve the real problem, but could it be enough in amblyopia? Evidence shows that patching improves amblyopia, however many have questioned this due to the lack of inclusion of an untreated control group. In this Amblyopia Treatment Study (ATS), 180 children ages 3-7 with moderate-severe amblyopia were randomized to be treated with either 2 hours of patching or spectacles alone (if required), after a 16-week period of refractive correction.

Key Points

• Patching led to a statistically significant increase in VA (0.6 lines) and BCVA (0.9 lines) compared to control group
• In a secondary cohort, children with mild amblyopia following spectacle correction experienced further improvement in BCVA and VA in the patching group

The ATS – patching versus correction study provided concrete evidence that patching the sound eye provides modest improvement in amblyopia in children ages 3-7.