Current Issue

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In this week’s issue

• Xanthelasma palpebrarum does not appear to be an independent risk factor for dyslipidemia or cardiovascular disease.
• Genetic risk factors for Fuchs dystrophy analyzed in a new cohort study suggest population-level screening could identify those at-risk for early intervention to preserve vision.
• Epithelial mapping alone lacks the sensitivity to detect subclinical keratoconus, making stromal-based imaging more reliable diagnostic tools. 
• Regular systemic follow-up is crucial for patients with eyelid sebaceous carcinoma due to high risk of distant metastases after initial presentation and surgery. 

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Ophthalmology
Association of xanthelasma palpebrarum with dyslipidemia and cardiovascular disease

Can your eyelids offer a clue about your heart health? Xanthelasma palpebrarum (XP) is a type of cutaneous xanthoma characterized by yellowish plaques around the eyelids caused by lipid deposits in the skin. Previous studies have produced conflicting results on the risk of cardiovascular disease (CVD) and dyslipidemias in patients with XP. In this retrospective, case-control study of patients at a single medical center, researchers compared the rates of dyslipidemias and CVD between patients with XP (n=203) and age- and sex-matched controls (n=2030). Overall, there was no significant difference in the prevalence of dyslipidemias (42% vs. 46%) or CVD (8.9% vs. 10%) between the XP and control groups. Additionally, serum lipid profiles, including total cholesterol (192 vs. 187), high-density lipoprotein (47 vs. 48), low-density lipoprotein (125 vs. 120), and triglyceride levels (105 vs. 111) were similar between both groups. These findings suggest that XP may not be an independent risk factor for dyslipidemia or CVD. However, further research is needed to explore its potential role and to determine whether these results apply to broader populations.

JAMA Ophthalmology

Repeat expansions: Fuchs edition

It’s a dystrophy mystery. Early intervention for individuals at risk of Fuchs endothelial corneal dystrophy (FECD) - a heterogenous, variably penetrant, autosomal dominant disorder - could help prevent irreversible endothelial deterioration and vision loss. While gene-targeted therapies are in development, success depends on accurately identifying at-risk individuals before significant changes occur. This multicenter cohort study examined 918 patients with a confirmed slit-lamp diagnosis of FECD at Moorfields Eye Hospital in London (2009 to 2023), assessing the impact of the CTG18.1 genotype on phenotypic outcomes such as age at recruitment and age at first keratoplasty. TCF4 repeat expansions were present in 77.3% of total cases (with at least one expanded copy), while 5.1% had biallelic expansions. Notably, these expansions were more prevalent among individuals of European and South Asian descent, with longer repeats and biallelic expansions linked to earlier time to keratoplasty and increased penetrance respectively. These findings highlight genetic risk factors for FECD among different populations and suggest that population-level screening could aid in identifying candidates for clinical trials and early intervention to prevent vision loss.

American Journal of Ophthalmology

Epithelial mapping falls short in detecting subclinical keratoconus

When it comes to subclinical keratoconus, epithelial mapping might be more of a dead-end than a roadmap. Patients with undiagnosed preoperative keratoconus face a significantly higher risk of mechanical instability following laser vision correction, making early detection of subclinical keratoconus (SKC) essential. This retrospective cross-sectional study evaluated whether epithelial thickness metrics from anterior segment optical coherence tomography (AS-OCT) could reliably detect SKC. The study included 100 control eyes with normal corneal topography and slit-lamp exams, 50 eyes with SKC, and 50 eyes with keratoconus (KC). Predictive accuracy was assessed using area under the receiver operating characteristic curve (AUROC). While the superonasal-inferotemporal (SN-IT) epithelial metric showed a statistically significant difference between SKC and control eyes (-0.81 mm vs. 0.41 mm), its diagnostic value was limited (AUROC=0.68). No other regional epithelial thickness metric effectively distinguished SKC from normal eyes. In contrast, Scheimpflug metrics and multiple OCT stromal metrics outperformed the best-performing epithelial metric (SN-IT) in distinguishing controls from SKC. These findings suggest that epithelial mapping alone lacks the sensitivity to detect SKC, likely because the disease does not induce sufficient curvature changes to alter epithelial thickness. Instead, epithelial remodeling becomes apparent only after keratoconus is visibly detectable on corneal imaging, emphasizing the need for stromal-based and topographic diagnostic tools.

British Journal of Ophthalmology

The importance of regular follow-up in eyelid sebaceous carcinoma

British Journal of Ophthalmologad to poor outcomes. Researchers at the University of Texas MD Anderson Cancer Center conducted a retrospective review to assess the impact of regular follow-up in patients with eyelid sebaceous carcinoma. Analyzing data from 138 patients (1999 to 2023), they examined the patterns and timing of nodal metastasis. They found that 22% of patients developed nodal metastasis, with 15 cases identified at initial diagnosis and 18 emerging during follow-up at a median of 12 months. Additionally, eight patients developed distant metastasis - most commonly the lung, liver, and spine - at a median time of 20 months after surgical resection. Notably, nearly 50% of patients with nodal metastasis had negative findings at initial presentation but later developed metastasis during follow-up. These findings underscore the critical role of ongoing systemic surveillance in patients with eyelid sebaceous carcinoma via referral to Head and Neck Oncologists, even when initial evaluations are negative for metastases.

Eye

Unveiling hidden social needs in eye care

An eye exam can uncover more than just vision problems. Health-related social needs (HRSN) like food insecurity and transportation barriers contribute to disparities in vision health. While screening for these needs is common in primary care, its role in ophthalmology remains largely unexplored. This retrospective cross-sectional study examined 1,413 adult patients at an academic eye center, analyzing screening questionnaire responses alongside demographic and visual acuity data. Overall, 13.7% of patients reported at least one HRSN, with food insecurity (7.6%) and transportation difficulties (5.1%) being the most common. Black patients, women, and those under 65 years old were significantly more likely to report an HRSN. Notably, patients with at least one HRSN had 55% higher odds of visual impairment (best corrected visual acuity worse than 20/40). Implementing HRSN screening in ophthalmology clinics helps identify vulnerable patients and can guide interventions to reduce vision health disparities.

British Journal of Ophthalmology

Alcohol use and hangovers impair vitreoretinal surgery

Even the steadiest hands may tremble after a night of drinking. Routine alcohol testing in physicians is a debated topic due to the lack of standard guidelines and concern for individual privacy. This study aimed to assess how different levels of alcohol consumption impact simulated surgical dexterity and tremor in experienced vitreoretinal surgeons. 11 senior vitreoretinal surgeons completed Eyesi surgical simulations after drinking alcohol to achieve a low-dose (0.06%-0.10%) or high-dose (0.11%-0.15%) BAC. They also completed surgical simulations after drinking a high-dose BAC and after a night of sleep to simulate a hangover. Performance was assessed the next morning after a night of high-dose alcohol consumption and sleep. Performance scores (0-700) (worst-best) and hand tremors (0-100) (best-worst) were recorded. Surgical performance significantly decreased after high-dose vs. low-dose alcohol use (−8.60±10.77 vs. −1.21±7.71). Hangover performance in the morning after high-dose alcohol use was similar to low-dose alcohol use (−1.76±14.47 vs. −1.21±7.71). A greater tremor was experienced during the hangover and after alcohol use, but a hangover caused a greater hand tremor score than after high-dose alcohol (7.33±21.65 vs. −4.12±17.17). Alcohol-related declines in surgical dexterity were dose-dependent, with notable impairment at higher doses. While dexterity improved after sleep, tremors worsened, raising concerns about next-day surgical performance during hangovers. Further studies are needed to assess real-world implications for patient safety, but this study suggests surgeons should not drink the same day of surgery and avoid high-dose alcohol the day before surgery as well.

Ahmed Baerveldt Comparison Study (ABC)

Go, Baerveldt, I choose you!...Er, I choose you, Ahmed! In the ABC trial, 276 patients with refractory glaucoma were randomized to receive either the Ahmed FP7 Glaucoma Valve or the Baerveldt 101-350 Glaucoma Implant and were followed for five years to assess intraocular pressure, number of glaucoma medications, and surgical failure rates.

Key Points:

• Both implants provided similar rates of surgical failure (39.4% Baerveldt, 44.7% Ahmed), but fewer failures in the Baerveldt group were from reoperation 
• The Ahmed group had significantly lower IOP at POD1 and POW1, but then the Baerveldt group had lower IOP measurements afterwards
• The Baerveldt group had a greater IOP reduction and lower IOP at five years than the Ahmed group at 5 years, but a greater percentage had persistent hypotony (13% vs. 2%) and loss of light perception (26% vs. 12%)
• The Baerveldt group generally had lower numbers of residual glaucoma medications, but this difference was not statistically significant at 5 years

Overall, the ABC study is a landmark study, because it showed that the Ahmed and Baerveldt had similar rates of surgical success in patients with refractory glaucoma. Although the Baerveldt might provide more IOP reduction and require fewer surgical interventions for glaucoma in the long-term, it’s safety must be weighed against the larger percentage of safety end points (hypotony, loss of light perception, etc.), compared with the Ahmed group.