Current Issue

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In this week’s issue:

• A new systematic review highlights best practices for managing postoperative photorefractive keratectomy pain, including NSAIDs and bandage soft contact lenses.
• Pars plana vitrectomy is associated with high anatomic reattachment (94.1%), but with limited postoperative visual acuity which may be useful for counseling patients.
• Cataract surgery may be complex in patients with retinitis pigmentosa, though it is associated with significant improvements in BCVA.

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https://anchor.fm/lens-pod/episodes/The-Lens-Newsletter-January-25--2023-e1ttmjk  

Ophthalmology

Reviewing management of post-photorefractive keratectomy pain 

PRK may cause pain, but it's worth it for the sight gain! Advanced surface ablation procedures, including photorefractive keratectomy (PRK), laser-assisted subepithelial keratectomy (LASEK), and epi-laser assisted in situ keratomileusis (epi-LASIK), are associated with more post-surgical pain compared to LASIK. This is thought to be caused by greater exposure and injury of corneal nerve fibers. A systematic review of the literature from February 2019 to October 2021 identified 51 studies that met inclusion criteria for evaluating pain control or healing after PRK. The consensus finding is that topical nonsteroidal anti-inflammatory drugs (NSAIDs) and bandage soft contact lenses (BCLs) are highly effective in reducing post-PRK pain with minimal side effects. Conversely, systemic opioids provide similar pain relief but come with the risk of addiction and other unfavorable side effects. Among the options available, high-potency oral NSAIDs, like diclofenac, may be the preferred medication for controlling postoperative pain. Additionally, systemic medications, topical anesthetics, and cold patches are more suitable as supplementary therapy rather than standalone pain management. Despite the challenges of objectively evaluating postoperative PRK pain, notable improvements have been demonstrated with certain interventions, including topical and oral NSAIDs and BCLs. 

JAMA Ophthalmology

Outcomes of vitrectomy in tractional retinal detachments in diabetic patients

Can vitrectomy help with tractional retinal detachments? A systematic review and meta-analysis of pars plana vitrectomy (PPV) for diabetic related tractional retinal detachment (dTRD) found that PPV was effective in achieving retinal reattachment, while final visual acuity remains low. This study analyzed data from 38 studies including 3839 eyes. The overall success rate of retinal reattachment after one surgery was 94.1% and the mean final visual acuity was 0.94 logMAR (approximately 6/53). It was also found that people with higher preoperative VA achieved higher postoperative vision, and that higher preoperative VA was the only factor associated with higher postoperative vision. The study concludes that PPV is an effective strategy for dTRD and that patients should be counseled on the guarded prognosis of dTRD, and the importance of early intervention.

American Journal of Ophthalmology

Appreciating the complexities of cataract surgery in patients with retinitis pigmentosa

Retinitis pigmentosa may make you feel in the dark, but with the right treatment, things can look a little clearer! Retinitis pigmentosa (RP) is a group of inherited retinal dystrophies that causes photoreceptor degeneration and may lead to substantial visual changes, commonly including night blindness and loss of peripheral visual fields. In patients with RP, cataracts tend to progress at an earlier age likely as a consequence of a heightened inflammatory state. While cataract surgery is often a reliable solution for patients, the prognosis for RP patients is less clear due to increased complications. In this retrospective clinical study, preoperative, intraoperative, and postoperative data from 295 eyes of 225 patients with RP were studied, including best-corrected visual acuity (BCVA) and various operative complications. Postoperatively, BCVA improved significantly in 56% of patients; from 20/214 to 20/129 in the first eye (95% CI = −0.31 to −0.13; P < .001) and, for those who had had surgery on each eye, from 20/126 to 20/73 in the second eye (95% CI = −0.32 to −0.15; P < .001). Intraoperative complications were reported in 6% of cases and were most commonly zonular dialysis. Postoperative complications were reported in 11% of cases and were most commonly exacerbations of existing macular edema. Though this retrospective study fails to provide standardized data, the sample size calls attention to important considerations in this patient population. While RP patients should warrant additional counsel when managing cataracts, these results suggest cataract surgery could lead to significant visual improvements.

American Journal of Ophthalmology

Vitreous cell density as an objective biomarker for posterior segment inflammation 

How much inflammation is in that uveitic eye? Current management of uveitis relies on clinician grading of anterior chamber cells, anterior chamber flare, and vitreous haze to determine disease severity and treatment response; however, these grading scales are limited due to being subjective, non-continuous, and poorly discriminatory at low levels of inflammation. In this retrospective, multicenter study, 74 eyes with a diagnosis of posterior uveitis were clinically evaluated and optical coherence tomography (OCT) was performed at 3 time points: active (T0), clinically improving (T1), and resolved (T2) inflammation. Objective grading of posterior segment inflammation was then performed by measuring the vitreous cell density and vitreous haze on each scan (n=222). Vitreous cell density and vitreous haze both significantly decreased with treatment of uveitis, however vitreous cell density significantly correlated with clinical grading and was superior to vitreous haze as a quantitative measure of intraocular inflammation. While further study is needed to examine the repeatability of these measurements, vitreous cell density appears to be a promising tool for grading posterior segment inflammation and may be a useful endpoint when designing randomized clinical trials.

The Age-Related Eye Disease Study (AREDS 2) - 2012

If at first you don’t “fully” succeed, try, try again. While AREDS1 showed that an oral supplement decreased the risk of developing advanced AMD in 5 years by 25%, observational data suggested that other nutrients may offer an additional protective benefit. AREDS2 aimed to evaluate the safety and efficacy of adding the antioxidant carotenoids lutein and zeaxanthin (L+Z) and/or omega-3 long-chain polyunsaturated fatty acids (LCPUFAs) in decreasing the risk of progressing to advanced AMD. The study also sought to determine the effect of reducing the amount of zinc in the AREDS oral supplement and omitting beta-carotene completely. 

Key Points: 

• No statistically significant reduction in disease progression was found in the groups assigned to take L+Z and/or omega-3 LCPUFAs in addition to the AREDS supplement
• No statistically significant reduction in disease progression was found with differing doses or zinc or with omission of beta-carotene.
• Significantly more cases of lung cancer occurred in patients who had history of smoking cigarettes and were taking beta-carotene (2%) versus those not taking beta carotene (0.9%); substituting beta-carotene for L+Z is appropriate

Together with AREDS1, which showed a 25% decrease in progression to advanced AMD, AREDS2 fine-tuned the notable vitamin formula by adding lutein and zeaxanthin and removing beta-carotene.

A 79 year old woman presents with headache and blurry vision in the left eye for 1 week. She was healthy until recently, reporting that she has “not been feeling her normal way.” Her visual acuity were 20/40 OD, 20/400 OS and the rest of her exam was normal except for the findings shown below:

Labs reveal elevated ESR and CRP levels. What is the most appropriate next step in managing this patient?

A. Schedule a temporal artery biopsy

B. Obtain a brain MRI

C. High-dose PO prednisone

D. High-dose IV methylprednisolone

Click Here For Answers!