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In this week’s issue

• Black, Asian, and Hispanic patients were more likely to have delays in initiation of treatment of nAMD
• Patients taking GLP-1 receptor agonists had a 51.7% reduced risk of developing non-infectious uveitis
• Implanting multifocal intraocular lenses in children showed improved visual acuity and stereopsis compared to a standard intraocular lens

Spotify Link:

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

JAMA Ophthalmology

GLP-1 receptor agonists have anti-inflammatory effects in the eye?

Just a weight loss pill? Think again. Glucagon-like-peptide-1 receptor agonists (GLP-1RAs), widely prescribed for type 2 diabetes and weight loss, have known systemic anti-inflammatory properties, but their effect on the eyes are not well explored. This retrospective cohort study, using a large database called TriNetX, examined the association between GLP-1RAs and the risk of developing non-infectious uveitis, which is an inflammatory condition affecting the uvea, retina, and other surrounding structures. This study included patients with retinal inflammation, anterior uveitis, and panuveitis. A total of 516,052 GLP-1RA users, regardless of diabetes status, had a 51.7% significantly reduced risk of developing uveitis compared to matched controls (RR 0.48). This protective effect remained consistent across both diabetic and non-diabetic groups. When looking at a subset of diabetic patients, those prescribed GLP-1RAs had a larger reduction in risk of developing uveitis than those on metformin (RR 0.58) or insulin (RR 0.57). This study adds to growing evidence that GLP-1RAs may modulate inflammation and extend benefits beyond just metabolic control, possibly offering a new line of defense against uveitis and ocular inflammation.

Ophthalmology

Disparities in presentation and anti-VEGF initiation for nAMD

Are there barriers to access anti-VEGF therapy for certain populations with nAMD? Age-related macular degeneration is the leading cause of blindness for adults 50 years or older in developed countries. Given the growing population, the prevalence of neovascular age-related macular degeneration (nAMD) is expected to rise dramatically by 2050. Advances in anti-vascular endothelial growth factor (anti-VEGF) have enabled the prevention and treatment of this condition. However, access to these treatments is limited by availability for various socioeconomic backgrounds. Previous literature has highlighted the importance of receiving anti-VEGF for diabetic macular edema and retinal vein occlusion; however, few have reported on the early treatment of nAMD. In this retrospective cohort study of 918,759 patients from the Intelligent Research in Sight Registry (IRIS), researchers sought to measure patient demographics, visual acuity, and treatment initiation within 12 months after first presentation with nAMD. Over 20% of patients with nAMD did not initiate treatment within 1 year of presentation. Lower treatment initiation rates were associated with Black race (RR 0.91), Asian race (RR 0.95), and Hispanic ethnicity (RR 0.96) when compared with White patients and non-Hispanic patients, respectively. Furthermore, low vision status (RR 0.49) and age younger than 60 were associated with lower treatment initiation rates. Enhanced efforts to reduce barriers to access and earlier intervention with anti-VEGF can mitigate irreversible vision loss in certain groups with nAMD.

American Journal of Ophthalmology (AJO) 

Multifocal IOL implantation in children with cataracts

Adults get multifocal IOLs… why can’t children? Pediatric cataracts are a major cause of childhood blindness and should be treated with surgery as soon as possible. The main goals of surgery are to avoid complications such as visual axis opacification, improve visual quality, and reduce dependence on glasses. The use of multifocal IOLs for children remains controversial due to potential visual disturbances (halo, glare, and decreased contrast sensitivity) that may negatively impact visual development. This prospective, non-randomized comparative study of 571 eyes of 402 children (311 eyes with multifocal; 260 eyes with monofocal) evaluated postoperative visual acuity, modulation transfer function, Strehl ratio, ocular scatter index, and stereopsis. Multifocal IOL implantation resulted in significantly better distance and near visual acuity. Multifocal IOLs implanted in Berger space had higher rates of spectacle independence, lower rates of corneal edema, transient intraocular hypertension, and visual axis opacification. Multifocal IOL implantation in Berger space had better visual outcomes and demonstrated safety for pediatric cataract patients.

Investigative Ophthalmology & Visual Science (IOVS)
Serum metabolomics for active vs. regressed retinoblastoma

Retinoblastoma metabolic markers? Retinoblastoma (RB) is the most common intraocular malignancy of childhood and monitoring treatment response remains challenging because tumor biopsy is contraindicated. Noninvasive biomarkers that reflect tumor activity could transform surveillance and personalized care. This study used ¹H nuclear magnetic resonance spectroscopy serum metabolomics to compare treatment-naïve active retinoblastoma (AR) with regressed tumors post-treatment (RT) and age-matched controls. Serum profiling revealed distinct metabolic signatures separating AR, RT, and controls, with clear shifts following chemotherapy. Active RB was characterized by elevated metabolites linked to energy metabolism and tumor growth including GABA, methionine, arginine, creatine, and lactate, many of which declined after successful treatment. Conversely, regressed tumors showed partial normalization of metabolic pathways, alongside unique alterations in amino acid and TCA-cycle intermediates. Longitudinal analysis across treatment cycles demonstrated patient-specific metabolic trajectories that closely tracked tumor regression status. Metabolites involved in glycolysis, amino acid metabolism, and the TCA cycle emerged as potential indicators of tumor activity and treatment response. These findings suggest that serum metabolomics can function as a noninvasive window into tumor biology, offering a promising approach for monitoring therapeutic efficacy and residual disease.

JAAPOS

Can AI help rethink patient education in pediatric ophthalmology?

Chat, can AI help clear things up for me? Clear, accessible patient education materials (PEMs) are essential in pediatric ophthalmology, where parental understanding directly affects treatment adherence and follow-up. Despite national recommendations for PEMs to be written at or below a 6th-grade reading level, many ophthalmology resources remain overly complex. As artificial intelligence becomes more embedded in clinical care, this study evaluated whether large language models (LLMs) could improve the readability and clarity of patient-facing materials without compromising quality or accuracy. In this cross-sectional analysis, investigators assessed 111 PEMs from the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), comparing baseline readability, quality, understandability, actionability, and accuracy with versions rewritten by ChatGPT-4 and Gemini Advanced. At baseline, PEMs were written at approximately a 9th grade reading level, with only 3.6% meeting 6th grade recommendations. ChatGPT-4 reduced readability to a 7th grade level while maintaining quality (median DISCERN 4), whereas Gemini Advanced achieved a 6th grade level but with a modest drop in quality (median DISCERN 3), and both models improved PEMAT understandability to over 90% with no detected misinformation. Overall, LLMs appear to be promising tools for improving the accessibility of pediatric ophthalmology education, though expert clinician review remains essential to preserve accuracy, nuance, and trust..  

Journal: British Journal of Ophthalmology

AI’s impact on ophthalmic disease screening services

Despite the advantages that AI offers ophthalmology, its impact on eye disease screening remains uncertain. Researchers in China conducted a scoping review to understand the extent to which AI-assisted diagnostic tools in eye disease screening improves the availability, accessibility, acceptability and quality of screening services globally. Ultimately, the authors included 42 articles, with half from low-and-middle-income countries. Twenty-eight studies looked at availability, 12 looked at acceptability, and the rest examined accessibility and service quality. Studies from high-income countries found AI to improve the cost-effectiveness of eye care services, particularly in remote or underserved areas. Studies from high-income countries also demonstrated high patient satisfaction. Studies from low-middle income countries demonstrated improved patient compliance. While only a few articles examined this, AI implementation resulted in rapid feedback of results and minimized waiting times, ultimately improving referral rates to ophthalmology. The authors suggest that to improve integration of AI into real world use, more studies are needed on improving screening processes and restructuring health systems around AI.

Diabetic Retinopathy Vitrectomy Study (DRVS) - 1990

Victory for the vitrectomy! In this 1990 trial, three distinct sub-investigations sought to:

1. Understand the natural history of proliferative diabetic retinopathy (PDR) 
2. Compare early vitrectomy (1-6 months) and traditional management (late vitrectomy, ≥12 months, or immediate vitrectomy if a retinal detachment occurred involving the macula) in PDR without significant vision loss (VA > 20/400)
3. Compare early vitrectomy and traditional management in PDR with significant vision loss (VA < 20/800, but not no light perception (NLP)) due to severe vitreous hemorrhage (VH)

Key Points

• Overall, patients in the early vitrectomy cohort had better visual outcomes than those in the delayed vitrectomy cohort
• Patients with Type 1 Diabetes and severe vision loss from VH, monocular patients (regardless of diabetes type), and patients with advanced PDR had better visual outcomes when vitrectomy was performed early
• No significant difference in visual outcomes was identified when comparing early versus late vitrectomy for Type 2 Diabetics
• Patients who received panretinal photocoagulation (PRP) had better visual outcome
• Regardless of intervention, NLP vision developed in 20% of eyes after vitreous hemorrhage

Overall, the DRVS is a landmark study because it highlighted how early vitrectomy can result in significantly better visual outcomes both immediately and long term for patients with Type 1 Diabetes, monocular patients, and those with advanced diabetic eye disease. Beyond removing hemorrhaged blood, vitrectomies relieve traction on the retina and eliminate the scaffolding that promotes new vessel proliferation.