Current Issue

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 In this week’s issue:

• Age-related macular degeneration increased risk of depression in a longitudinal study of patients from a Korean database 
• Exploratory analysis of ophthalmology literature attempts to make sense of productivity and citation metrics
• A sutureless ptosis repair surgery shows promising results in terms of eyelid elevation, symmetry, and complication rate
• The hypoxia-inducible factor 1-alpha transcription factor emerges as a potential therapeutic target for autoimmune uveitis

Ophthalmology

Shedding light on the dark connection between AMD and mental health

Should ophthalmologists be keeping an eye on both vision and mental health? Age-related macular degeneration (AMD), the most common cause of blindness in developed countries, is a degenerative disease of the macula that leads to progressive loss of central vision in the elderly. AMD significantly impacts patients’ quality of life and has been associated with depression. However, prior longitudinal studies had conflicting results due to limitations of study design and sample size. This retrospective cohort study used data from 3,599,589 individuals aged 50 years and older without a history of depression. Data was sourced from the Korea National Health Insurance Service (NHIS) database. The depression outcome variable was determined based on diagnostic codes during follow-up, and individuals were followed until the occurrence of depression, death, or the end of the study period. There were 1,037,088 cases of incident depression over an average follow-up period of 8.52 years. Multivariable survival models showed a greater risk of incident depression in patients with AMD compared to those without (hazard ratio 1.15, 95% CI, 1.13–1.17), and further increased risk in those with AMD and visual disability (hazard ratio 1.23, 95% CI, 1.16–1.30). Stratified analysis ultimately revealed a greater association between AMD and depression in younger individuals and males. This study emphasizes the importance of recognizing and addressing mental health in patients with AMD, including vigilance in detecting depressive symptoms in the ophthalmology clinic setting.  

JAMA Ophthalmology

An analysis of ophthalmology journals and citation metrics

What is the publishing landscape in ophthalmology? Providers rely on published literature to stay current with advances in eye care. However, the large variety of journals, publishers, and citation metrics in the field can be overwhelming. The h-index is one such metric that, in broad terms, compares the number of articles from a given journal, author, or collection to the number of times those articles have been cited. Larger values suggest a larger quantity of articles and citations of those articles. To begin synthesizing these factors and better guide readers, a bibliometric analysis was performed on 335 ophthalmology journals and 471,184 articles. The overall h-index for articles from all 335 journals was 494. Of these journals, Ophthalmology had the top h-index of 297 and American Journal of Ophthalmology had the highest number of articles at 38,441. In an analysis of individual authors, Ronald Klein, MD had the highest h-index of 126 and Carol L. Shields, MD had the largest number of ophthalmologic publications at 1,400 articles. Articles from Johns Hopkins University had the highest h-index, while Harvard University had the greatest number of articles. These data may help authors and readers better understand the productivity and audience of journals, institutions, individuals, and ophthalmology literature as a whole. 

American Journal of Ophthalmology

Innovative approach: sutureless conjunctiva-sparing ptosis repair

Who needs stitches? Sutureless eye surgery rethinks droopy eyelid fix. The future of eyelid lift surgery may be here - and it doesn't involve sutures. Müller muscle-conjunctival resection (MMCR) is a common method to correct mild to moderate blepharoptosis, but it necessitates the removal of healthy tissue and exposes the cornea to sutures. A novel sutureless technique called conjunctiva sparing Müllerectomy (CSM) shows promise to potentially revolutionize ptosis repair. This retrospective study evaluated the records and postoperative photographs of 100 patients (171 eyes) who underwent sutureless CSM surgery with postoperative monitoring for at least 6 months. The average change in upper eyelid margin to light reflex distance (MRD1) and palpebral fissure height (PFH) from pre-op to six months post-op were 2.85 mm ± 0.98 mm and 2.60 mm ± 1.38 mm respectively, indicative of successful repairs. Of these cases, 91% achieved symmetry within 1 mm for both MRD1 and PFH. Sutureless CSM was notably efficient, taking roughly half the time compared to traditional MMCR, and no corneal abrasions or ocular complications were recorded. The reoperation rate was 2.3%. Ultimately, the study concludes that sutureless CSM offers a promising alternative to traditional MMCR, showing encouraging long-term outcomes, symmetry, shorter operation times, and a low complication rate. 

IOVS

HIF1α inhibitors as treatment target for autoimmune uveitis

Seesaws are fun for kids, not T cells. Autoimmune uveitis may be caused by an imbalance between pro- and anti-inflammatory T-cells, leading to chronic and recurrent destructive attacks on ocular tissue which can cause blindness. Corticosteroids and immunosuppressants are mainstay treatments but have systemic side effects. Thus, there is a need for more targeted treatments to reduce the potential for adverse effects. This study aimed to identify potential therapeutic targets by analyzing single-cell RNA-sequencing data from cervical lymph nodes of a mouse model of experimental autoimmune uveitis (EAU). This was achieved by analyzing differential expression of mRNA transcripts between disease and control mice. Their results confirmed upregulation of immune cell activation and inflammation pathways. Furthermore, they found that the hypoxia-inducible factor 1-alpha (HIF1α) transcription factor, involved in inducing cellular adaptations to low oxygen, showed increased expression in T cells in the EAU mouse model. This finding was recapitulated in the human blood samples. Administering a HIF1α inhibitor to the mice reduced ocular symptoms and helped restore the balance of pro- and anti-inflammatory T-cell activity. The authors conclude that HIF1α inhibitors already on the market might have a potential role as a targeted treatment option for autoimmune uveitis.

JAMA Network Open

Red light therapy: a new way to prevent myopia in children?

Is it time to change your kid’s favorite color? Myopia is one of the most common eye diseases worldwide, affecting up to 80-90% of children in some parts of Asia. Early-onset myopia has been correlated with increased risk of progression to high myopia and related vision-threatening conditions. Repeated Low-Level Red-Light Therapy (RLRL) is an emerging treatment that has shown early success in reducing myopia progression in children. In this study, authors explore RLRL as myopia prophylaxis in children with premyopia. This was a 12-month, parallel-group, randomized clinical trial of children with premyopia in China. One hundred and thirty-nine children were assigned to both the intervention group (RLRL therapy) and the control group, for a total of 278 participants. Children in the RLRL intervention group received therapy twice per day, five days per week. Intention-to-treat analysis showed that the 12-month incidence of myopia was 61.3% in the control group and 40.8% in the intervention group (33.4% relative reduction). The difference was greater in per-protocol analysis, wherein 28.1% of children who received uninterrupted RLRL therapy developed incident myopia (54.1% relative reduction). There was also a statistically significant reduction in myopic shift, measured by difference in axial length and spherical equivalent refraction, for the RLRL intervention group compared to the control group. With no visual or structural adverse effects reported in this study, early outcomes reveal RLRL as a promising new intervention for myopia prevention in premyopic children.

Collaborative Longitudinal Evaluation of Keratoconus (CLEK)

Did you know Steph Curry has keratoconus? Imagine how tough it would be for him if he couldn’t see the rim anymore. In the 2007 CLEK study, 1209 patients with keratoconus were enrolled to prospectively evaluate changes in vision, corneal status, corneal curvature, and vision-related quality of life (V-QoL) changes over time.

Key Points:

• 53% of enrolled patients reported a history of atopy, 50% reported a history of vigorous eye rubbing
• Patients experienced a 2.03 letter (high-contrast) and 4.06 letter (low-contrast) reduction in BCVA at 7 years
• Of the 878 patients without corneal scarring at baseline, the 5-year incidence of scarring was 14% 
• 11 NEI-VFQ scales were measured, with almost all measurements showing modest decline in V-QoL over a 7-year period (increase in dependency being the most significant)

Overall, the CLEK study is a landmark study because it was a large-scale natural history study that provided clinicians with data on the natural progression of keratoconus. Furthermore, it highlighted that keratoconus is a debilitating disease, objectively measuring the patient-perceived significant impact it plays in progressively worsening quality of life.

A 78-year-old female patient presents with acute onset decreased vision in the right eye. She denies any recent falls, trauma or associated ocular pain, photophobia, or fever/chills. Ocular history includes non-granulomatous anterior uveitis and secondary glaucoma. Surgical history includes cataract and trabeculectomy surgery. Visual acuity was light perception and her intraocular pressure was 5. OCT image is shown.

Which of the following would have most likely caused this finding on imaging?

A. Age-related macular degeneration

B. Glaucoma surgery

C. Choroidal melanoma

D. Posterior scleritis

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