The most important ophthalmology research updates, delivered directly to you.
The most important ophthalmology research updates, delivered directly to you.
In this week’s issue
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Ophthalmology
Trends in plasma exchange therapy for management of optic neuritis
Treating optic neuritis can be quite perPLEXing! Optic neuritis (ON) is an inflammatory disorder of the optic nerve that can lead to vision loss. While the exact treatment regimen depends on a number of factors, intravenous corticosteroids are often the initial step. More recently, retrospective studies have also reported on the use of plasma exchange (PLEX) therapy for ON. In this retrospective cross-sectional study using data from the National Inpatient Sample database, ICD-9 and 10 codes were used to identify patients with a primary diagnosis of ON between 2000-2020 (n=11,209). During the study period, rates of PLEX use increased from 0.63% to 5.46%. Subset analysis using only ICD-10 codes (n=3215) showed that PLEX therapy was most frequently utilized for ON associated with neuromyelitis optica spectrum disorder (21.21%) and least frequently for multiple sclerosis (3.80%). The PLEX cohort also had higher total hospital charges ($115,949 vs $38,682) and a longer length of stay (8.82 days vs 3.43 days). These results suggest increasing familiarity with and perceived efficacy of PLEX therapy for ON, especially for antibody-mediated and steroid-resistant cases. However, prospective randomized trials are needed to further establish safety and efficacy parameters.
JAMA Ophthalmology
Association between intraocular inflammation & faricimab injections
Are we there yet? While various VEGF (vascular endothelial growth factor) inhibitors have been approved for use in neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME), the randomized clinical trials used to establish efficacy and tolerability are insufficient to detect rare, adverse events. As a stop-gap between approval and formal phase 4 studies that analyze real-world data, clinical case reports provide information regarding the drugs’ safety profile. In this single-center retrospective case series, data from patients referred for intraocular inflammation shortly after receiving a faricimab intravitreal injection between June 2022 and March 2024 were analyzed. Of the 12 eyes from 7 patients referred for intraocular inflammation, 10 eyes and 6 patients had moderate non-infectious inflammation and 1 patient had bilateral non-infectious anterior uveitis with concomitant central retinal vein occlusion causing irreversible vision loss. The inflammatory events occurred after a median of 3.5 injections and with a median onset of 28 days after injection. While this case series does not demonstrate causation between faricimab injections and intraocular inflammatory events, it does suggest the importance of regularly monitoring eyes receiving injections in order to address inflammation quickly.
American Journal of Ophthalmology
Racial disparities in MIGS for the management of POAG
Racial disparities continue to affect access to essential glaucoma treatments. Microinvasive glaucoma surgeries (MIGS) have become popular early intervention for mild to moderate primary open-angle glaucoma (POAG). Despite the advantages of MIGS, healthcare disparities persist in glaucoma surgical management, particularly for African American patients who experience higher rates of visual impairment and blindness compared to White patients. This retrospective cohort study analyzed 63,418 patients with mild or moderate POAG, comparing MIGS utilization between African American (n=31,709) and non-African American (n=31,709) cohorts. Results showed that African American patients (n=1,268) were less likely to receive MIGS for the management of POAG than non-African American patients (n=1,508) (OR: 0.834; 95% CI: 0.773–0.900). Disparities in timing of diagnosis, rate of disease progression, and access to medical screening and treatment may contribute to the lower rates of MIGS among the African American patients
British Journal of Ophthalmology
CSF as an adjunct to MRI for detection of CNSL in VRL patients
At the time of vitreoretinal lymphoma (VRL) diagnosis, 37% of patients have a concurrent central nervous system lymphoma (CNSL) and 80% of patients with VRL may develop CNSL at some point in their disease course. Given the significant portion of individuals with both VRL and a CNSL, determining whether an individual with VRL has CNSL becomes an important consideration. This is especially critical given the 5-year morbidity and mortality of CNSL is around 30%–40%. Currently, CNSL is a disease process that can be asymptomatic early in its disease course, therefore the primary modality of diagnosis is via MRI. Many physicians also utilize CSF, even in patients with a negative brain MRI. A recent prospective observational study at the Memorial Sloan Kettering Cancer Center sought to assess whether CSF assessment is needed in patients with negative MRIs. The study aimed to evaluate the proportion of patients with biopsy confirmed CNSL whose MRIs were negative but whose CSF was suspicious for lymphoma. Of the 65 patients included in the study, 30 had negative MRI brain and CSF, 16 had positive brain MRI and negative CSF, 8 had both positive MRI brain and CSF. Importantly, 11 patients (16.9%) had CSF suspicious for lymphoma without positive findings on MRI of the brain. While the majority of patients with CNSL had characteristic MRI findings, CSF analysis may detect CNSL in some patients with normal MRIs.
Eye
Visual impacts of synthetic cannabinoids: A case-control study
Unveiling the hidden effects of synthetic cannabinoid use. This study involved 90 male participants divided into three groups: seropositive synthetic cannabinoid (SC) users, seronegative users, and healthy controls. “Seropositivity” was assessed via urine toxicology assessment. Ophthalmic assessments were conducted to measure intraocular pressure (IOP), retinal thickness, choroidal structure, retinal nerve fiber layer thickness and choroidal vascularity index (CVI). While it is well-known that both natural and synthetic cannabinoids can lower IOP, their impact on the retina and choroid is less understood. The study found that IOP was significantly lower in seropositive SC users compared to both seronegative users and controls, and that choroidal thickness, total area, luminal area, and stromal area were all significantly lower in the seropositive group. These findings underscore the need for further research into the long-term ocular effects of synthetic cannabinoids, particularly their potential role in treating conditions like glaucoma.
Ophthalmology Retina
Vitreoretinal lymphoma: Presentation, diagnosis, and treatment
A dangerous needle in the ophthalmic haystack: vitreoretinal lymphoma. Vitreoretinal (VR) non-Hodgkin B-cell lymphoma is a rare but deadly malignancy. The incidence is low (1 in 2 million), accounting for <1% of ocular malignancy, and medical guidelines are scarce, leading to limited direction on how to manage these patients. This study reviews how patients diagnosed with this condition were treated and tested over a recent two-year period. An international ophthalmology registry reported on the clinical features and treatment of 80 patients with VR lymphoma between 2020 and 2022. Lymphoma was bilateral in 65% of patients and primarily located in the eye in 78%. Vitreous involvement occurred in 89% of affected eyes, while the retina was involved in 46%. The diagnosis was based on ocular specimens in 80% of cases, typically using cytology, and 95% of patients began treatment within six months, with intravitreal methotrexate being the most common treatment. This study highlights that visual impairment masquerading as uveitis is frequent in this extremely rare condition, with diagnosis of VR lymphoma often relying on cellular studies and treatment usually involving intravitreal chemotherapy (e.g. methotrexate).
Amblyopia Treatment Study (ATS) – Patching vs. Correction
Usually a quick patch doesn’t solve the real problem, but could it be enough in amblyopia? Evidence shows that patching improves amblyopia, however many have questioned this due to the lack of inclusion of an untreated control group. In this Amblyopia Treatment Study (ATS), 180 children ages 3-7 with moderate-severe amblyopia were randomized to be treated with either 2 hours of patching or spectacles alone (if required), after a 16-week period of refractive correction.
Key Points:
The ATS – patching versus correction study provided concrete evidence that patching the sound eye provides modest improvement in amblyopia in children ages 3-7.
You are the resident on-call when a 72-year-old man presents with a sudden loss of vision in the lower portion of his right visual field. He has also been experiencing a headache on his right side that has not responded to Tylenol or Ibuprofen. This morning, he noticed a new pain while chewing. BCVA is HM OD and 20/25 OS. Fundus exam (shown below) of the right eye is suggestive of AION (anterior ischemic optic neuropathy). Given these symptoms and exam findings, you suspect a diagnosis of Giant Cell Arteritis (GCA). You begin treatment with 60mg per day of oral prednisolone. You plan to confirm your diagnosis with a temporal artery biopsy.
The fundus image demonstrates AION due to GCA, likely caused by inflammatory occlusion of the posterior ciliary arteries.
Which of the following statements regarding this case is TRUE?
A. If ordered, blood tests would show decreased erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP).
B. If not treated, in up to 60% of patients the second eye may become blind within the next 6-12 months.
C. 80% of patients will regain lost vision after completing the steroid therapy.
D. In this case, initial treatment with intravenous methylprednisolone would have been more appropriate.
E. Due to the potential complications of steroid treatment, you should have waited for biopsy results before initiating treatment.
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