Current Issue

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In this week’s issue:

• Posterior open globe injury extension independently portends worse visual and anatomic outcomes.
• Deep learning algorithms provide insight into neurological dysfunction in Parkinson’s using fundus photographs.
• The most common eye diagnoses in emergency rooms are conjunctivitis, corneal abrasions, and dry eye. 
• Increased physical activity is associated with slower rates of macular ganglion cell-inner plexiform layer thinning. 

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Register today: www.realworldophthalmology.com/tickets because space is limited! Registering also gives you exclusive access meeting content for 90 days and early bird invites to our in-person networking events at the major meetings.  

Too busy to read The Lens? Listen to this week's summaries here!  https://podcasters.spotify.com/pod/show/lens-pod/episodes/The-Lens-Newsletter-March-29--2023-e219po4  

Ophthalmology

Posterior open globe injuries associated with worse visual and anatomic outcomes

This time, we don’t want to go the distance. Open globe injuries (OGIs) have the potential to inflict significant loss of vision and ocular morbidity. Its effects vary based on the severity of the injury and according to a new study, the location of the injury as well. OGIs are classified by the depth of the wound, ranging from Zone 1 (involves the cornea anterior to the limbus) to Zone 3 (extends > 5mm beyond the limbus). Zone 3 (Z3) contains approximately 67% of the anterior-posterior spherical length of the eye, and therefore can be subdivided into anterior (5-10mm beyond the limbus) and posterior (> 10mm) regions. This retrospective, single cohort study evaluated visual and anatomic outcomes of far, posterior Z3 OGIs compared to anterior Z3 OGIs. 258 eyes were analyzed, and outcomes were assessed after 3 months of follow-up care. Visual acuity was significantly worse in eyes with posterior Z3 OGI, with greater prevalence of patients exhibiting NLP (pZ3: 38%; aZ3: 17%; P < 0.003) and lacking count fingers vision (pZ3: 72%; aZ3: 43%; P < 0.002). Patients with posterior Z3 OGI were also significantly more likely to develop poor anatomic outcomes including phthisis, enucleation, and need for keratoprosthesis (p<0.03). This study suggests wound location within Z3 impacts overall prognosis of OGI. These results may allow providers to offer better patient guidance and counseling as well as inform surgical decision making.  

JAMA Ophthalmology

An algorithm to identify neurologic dysfunction with fundus photographs in Parkinson disease

Are eyes the windows to Parkinson’s Disease? Identifying neurologic dysfunction in Parkinson disease (PD) patients relies on complex neurologic testing, which can be challenging and time intensive. Predictive tools, such as algorithms, can be helpful in clinical settings to treat patients more efficiently. The goal of this study was to develop an algorithm that could predict the Hoehn and Yahr (H-Y) scale and Unified Parkinson’s Disease Rating Scale part III (UPDRS-III) score for PD patients using fundus images. A prospective study was performed with fundus photographs from 266 patients with PD and 349 participants with non-PD atypical motor abnormalities as the control. The algorithm showed high sensitivity above 80% for the H-Y scale and UPDRS-III score, but lower specificity between 66% to 67%. This decision analytical model provides information into the neurologic dysfunction among PD patients by demonstrating the way in which a deep learning method can be used to evaluate the connections between the retina and brain. Overall, the study highlights the potential for algorithms and machine learning to improve patient assessments in clinical settings. 

American Journal of Ophthalmology

The most common eye diseases in the emergency department 

Get some assistance, but skip the ambulance... Ocular emergencies, though comprising only 1.5% of visits across the country’s emergency departments annually, can be challenging to diagnose for all clinicians. In order to streamline patient care, mitigate emergency department overcrowding, and alleviate patient cost burden, it is important to identify the most common ophthalmic emergencies. This multicenter study compiled records from 64,988 patients who visited one of three stand-alone eye emergency departments in 2019. The primary ophthalmic diagnosis was extracted from these visits. The most common overall diagnosis was conjunctivitis (44.4%) followed by corneal abrasions (5.61%), dry eyes (4.49%), posterior vitreous detachments (4.15%), and chalazions (3.71%). More serious conditions diagnosed included corneal ulcers (3.01%), retinal detachments (2.51%), and glaucoma (2.12%). The most common diagnoses found were largely non-emergent. Patients in the United States spend on average 7.30 hours in an emergency room visit compared to 1.55 hours in a clinic visit. Thus, low-acuity eye emergencies are better suited for urgent ophthalmology clinic visits. Institutions without an eye-specific emergency department can consider training healthcare workers who do not specialize in ophthalmology to be more familiar with common eye conditions in order to improve care.  

IOVS

Physical activity is associated with macular thickness

Ten thousand steps a day to keep the ophthalmologist away? Exercise has been proposed to correlate with progression of various ophthalmologic diseases. This multi-cohort study explored this phenomenon using OCT-derived metrics of macular thinning in glaucoma. Rate of longitudinal macular ganglion cell-inner plexiform layer (GCIPL) thinning was measured in 735 eyes of 388 adults with early primary open-angle glaucoma (in the Progression Risk of Glaucoma: RElevant SNPs with Significant Association or PROGRESSA Study). Ophthalmologic measures were correlated with participants’ physical activity as tracked by Fitbit wearable fitness devices. Results were then compared with cross-sectional data from 8862 eyes of 6152 participants in the United Kingdom’s Biobank. Analysis was conducted using stepwise regression, ultimately identifying covariates of demographic, ocular, and cardiovascular traits. Results showed that increased physical activity correlated with slower rates of macular GCIPL thinning (beta = 0.07 µm/y/SD; 95% confidence interval [CI], 0.03-0.13; P = 0.003). Associations persisted in cross-sectional data from UK Biobank patients without history of ophthalmologic disease. This study indicates a neuroprotective effect of physical exercise on retinal health in two large cohorts, though limitations including a cross-sectional view of physical activity highlight the need for longitudinal studies to assess whether ongoing exercise can predict disease progression.

JAMA Network Open

Global prevalence of diabetic retinopathy in pediatric type 2 diabetes 

Where in the world is pediatric diabetic retinopathy? According to the Centers for Diseases Control and Prevention, children living with type 2 diabetes (T2D) increased from 34 per 100,000 to 67 per 100,000 between the years 2001 – 2017. Diabetic retinopathy (DR) in adults with T2D has been a leading cause of blindness in adults worldwide; however, the global burden of DR in children with T2D is unknown. In this systematic review and meta-analysis, researchers sought to survey studies with 10 or more participants that reported the prevalence of DR from more than 1900 articles. Of the 27 qualifying studies, it was estimated that the global prevalence of DR in the pediatric population was about 28% at more than 5 years after their diagnosis (95% CI, 12.84%-46.45%; I2 = 96%). This was more than three times the estimated prevalence at less than 5 years after diagnosis. Because of this vast increase in prevalence, annual screening with fundus photography at onset of T2D is the best assessment for early detection of DR in pediatric patients.

Ranibizumab vs. Verteporfin PDT for neovascular AMD (ANCHOR)

Anchors aweigh! Say farewell to verteporfin and ahoy to ranibizumab. In this double-masked phase III clinical trial, ranibizumab, an anti-VEGF antibody, was compared with the standard of care of the time - verteporfin photodynamic therapy (PDT). 423 patients with age-related macular degeneration (AMD) with predominantly classic neovascularization (CNV) were randomized to receive either verteporfin PDT, or monthly intravitreal ranibizumab (0.3 mg or 0.5 mg) for 2 years.

Key Points:

• Ranibizumab was superior in preserving and improving visual acuity: ~90% lost fewer than 15 letters, and 34-41% gained >15 letters compared to ~65% and 6.3% in the PDT group
• Ranibizumab treatment significantly improved the size and severity of angiographic lesions, stabilizing the total lesion area and decreasing area of classic CNV
• Ranibizumab did not increase risk of ocular or systemic adverse events

Results of the ANCHOR trial confirmed the clinical benefit of ranibizumab found in the landmark MARINA study, and demonstrated that ranibizumab outperformed verteporfin PDT in all measures evaluated in AMD patients with predominantly classical CNV lesions. Together they were instrumental in altering clinical practice and providing new hope in patients with numerous retinal conditions.

A nine month old boy presents to the clinic with tearing and light sensitivity in the left eye. His mother also complains that he is constantly rubbing his eye. The boy is poorly cooperative with the examination. External examination findings are shown below:

What is the most appropriate next step?

A. Antibiotics ointment

B. NLD probing & irrigation

C. Examination under anesthesia

D. Uveitis work-up

Click Here For Answers!