Current Issue

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In this week’s issue

• Orbital masses and red eyes correlated with worse prognosis in retinoblastoma. 
• Study suggests women in ACGME-accredited ophthalmology residencies attain lower surgical and procedural volumes than their male counterparts.
• Air pollution exposure could increase risk of diabetic retinopathy and retinal detachment.
• Healthy lifestyle factors may improve retinal health and reduce risk of age-related macular degeneration.
• Anti-VEGF treatment in Retinopathy of Prematurity shows promise in promoting healthy vascular extension of the peripheral retina.

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Ophthalmology
Staging retinoblastoma based on presenting signs

Some clinical signs at presentation portend an advanced retinoblastoma stage. Retinoblastoma, the most common ocular malignancy in children, can present with various clinical signs including red eye, leukocoria, orbital cellulitis, orbital mass, iris color change, strabismus, and hyphema. Until now, the association of each presenting clinical sign with cancer stage has remained poorly understood. In this retrospective, cross-sectional study, data from 4,578 retinoblastoma patients from 259 centers across 121 countries were gathered and analyzed to determine which clinical signs were associated with early vs. advanced disease. Leukocoria or strabismus (two of the three most common presenting signs of retinoblastoma globally) were associated with relatively lower likelihoods of advanced disease (58.1% and 46.1%, respectively). In contrast, an orbital mass (the other most common presenting sign globally) carried the highest likelihood of advanced disease (95.7%), followed closely by red eye (89.2%). These data have the potential to arm ophthalmologists with an immediate, albeit imperfect, estimation of retinoblastoma severity which may prompt an expedited, and potentially curative, clinical course.

JAMA Ophthalmology
Gender differences in surgical volumes in ophthalmology residencies

Four years of training side-by-side, but not case-by-case? A previous report, which included approximately 20% of US residency programs, reported lower surgical volumes for female residents. Given this relatively small sample, this study sought to examine whether this trend was representative of all residents in ACGME-accredited ophthalmology programs and whether underrepresented in medicine (URiM) trainees have similar surgical experiences compared to non-URiM trainees. A retrospective, longitudinal cohort study was conducted that included all graduates from ACGME-accredited ophthalmology residency programs between 2014 and 2023. Out of 4811 residents, 41.6% were female, 58.4% were male, and 7.1% were URiM. In this cohort, female residents performed significantly fewer primary cataract surgeries and procedures than their male colleagues (-4.4% and -7.4% respectively) whereas URiM status was not associated with a statistically significant difference in cataract surgery volume but was associated with fewer total procedures compared to non-URiM trainees (-5.3%). Overall, these findings highlight a persistent gender gap in surgical training during residency, warranting further research to identify underlying causes. 

American Journal of Ophthalmology
Air pollution: An invisible culprit behind vision-threatening diseases

Breathing in bad air? Your eyes might be feeling it too! Vision-threatening ocular diseases can have significant clinical and public health implications, making the identification of modifiable risk factors important. While air pollution has been linked to various systemic diseases and eye health, its impact on a wider range of eye conditions, particularly in the context of myopia, remains poorly understood. To address this, a cohort study used data from 114,930 adults in the UK Biobank to examine the association between specific air pollutants and the development of five common eye diseases: diabetic retinopathy, retinal detachment, glaucoma, cataracts, and macular degeneration, stratifying results by myopia status. Air pollution exposure was estimated based on participants' residential locations over time. Elevated levels of particulate matter (PM10) and nitrogen oxides (NOx) were significantly associated with an increased risk of developing diabetic retinopathy among myopic participants, with hazard ratios of 1.11 (95% CI: 1.01-1.23) and 1.22 (95% CI: 1.02-1.45), respectively. Higher exposure to PM10 was found to increase the incidence of diabetic retinopathy, retinal detachment, and macular degeneration, particularly in the low-to-moderate myopia subgroup. This study highlights the need for targeted interventions to reduce air pollution exposure in at-risk populations.

British Journal of Ophthalmology

Can a healthy lifestyle protect your retina?

Your workout and green juices might be doing more for your eyes than you think. While previous studies have linked individual lifestyle behaviors like smoking and activity levels to retinal health, this study explored how a combination of healthy habits influences retinal health. Researchers analyzed data from the UK Biobank, assessing the association between a six-factor healthy lifestyle score (based on physical activity, diet, sleep duration, smoking status, alcohol use, and bodyweight) and the risk of age-related macular degeneration (AMD) and retinal vascular occlusion (RVO) as well as retinal imaging metrics. Those with the healthiest lifestyles (score of 5-6) had a 29% lower risk of AMD, a 25% lower risk of RVO, greater retinal thickness in the retinal nerve fiber layer, ganglion cell-inner plexiform layer, and photoreceptor segments, and improved retinal vascular morphology compared to those with the worst lifestyles (score of 0-1). Lower levels of inflammation helped explain part of the association between healthy lifestyles and better retinal health. These findings suggest that adopting healthier lifestyle habits may help maintain retinal health and lower the risk of sight-threatening disease. 

Eye

Low flow, high stakes: The choroid’s role in diabetic foveal neovascularization 

The fovea is a battlefield - especially when blood flow in the choroid runs dry. Diabetic foveal neovascularization (DFN) is a rare but sight-threatening complication of proliferative diabetic retinopathy (PDR), and its underlying mechanism remains poorly understood. Recent attention has turned to the role of local blood flow disturbances, particularly in the choroid, as a potential trigger for this aberrant vessel growth. In this cross-sectional observational study, researchers compared 18 eyes of 18 adult patients each from three groups: healthy controls, PDR with DFN, and PDR without DFN, analyzing blood flow via adjusted flow index (AFI) in the retinal and choriocapillaris layers from optical coherence tomography angiography (OCTA) images. Eyes with DFN showed significantly reduced choriocapillaris flow, especially in the subfoveal area, compared to healthy eyes and PDR eyes without DFN. Retinal plexus flow did not differ significantly among groups. These findings suggest that localized choroidal hypoperfusion may be a key factor in DFN development, highlighting the subfoveal choriocapillaris as a potential early biomarker for neovascularization in diabetic eye disease.

American Journal of Ophthalmology

Anti-VEGF effect on peripheral vascularization in ROP 

Anti-angiogenic factors may promote healthy peripheral vascularization in retinopathy of prematurity? Retinopathy of prematurity (ROP) is a leading cause of childhood blindness in the US and worldwide. Current therapy involves interfering with pathologic angiogenesis using anti-vascular endothelial growth factor (VEGF) therapy, cryotherapy and laser. Preliminary studies have indicated that anti-VEGF both inhibits pathologic intravitreal neovascularization and simultaneously extends retinal vascularization peripherally. This retrospective study investigated the effect of intravitreal injection with the anti-VEGF agent bevacizumab in 11 infants with type 1 ROP compared to 11 infants with less severe ROP matched by gestational age and birthweight. At baseline, type 1 ROP infants appeared to have shorter temporal vascularization compared to matched controls without statistical significance (3667±547 pixels vs. 4262±937 pixels; p=0.08) and at follow-up, no difference was found between the groups. However, type 1 ROP infants treated with bevacizumab showed significantly greater vascular extension compared to controls (p=0.003). These findings support laboratory studies that intravitreal anti-VEGF agents may promote healthy peripheral angiogenesis in ROP while reducing pathologic angiogenesis.

I spy with AI: Spotting pathologic myopia before it blinds

Pathologic myopia (PM) is a leading cause of irreversible vision loss, particularly in East Asia, and early detection is critical for timely intervention. However, screening massive populations for subtle signs like fundus tessellation and early-stage maculopathy is resource-intensive and subjective. This study developed a deep learning system trained on 10,347 color fundus photos to classify myopic maculopathy into four progressive categories, using the META-PM-based grading scheme. The model, based on the EfficientNet-B8 architecture, was trained and validated on internal data from the Shanghai Eye Disease Prevention and Treatment Center, with external testing on an independent dataset from two hospitals. It achieved AUCs of 0.99–1.00 in classifying various stages of PM, outperforming ophthalmologists in detecting early signs such as severe tessellation and early-stage PM. At the image level, the model’s sensitivity ranged from 88% to 96% and specificity from 93% to 99.5%, showing strong generalizability across different patient populations and clinical settings. This work suggests that deep learning tools can be integrated into screening programs to improve early detection and reduce the burden of PM-related vision loss, particularly in high-prevalence, low-resource regions.

Laser in Glaucoma and Ocular Hypertension (LiGHT)

An eye drop a day keeps glaucoma at bay, but a laser one time can save a whole lotta dime. Prior to the LiGHT study, the standard first step of therapy for open-angle glaucoma (OAG) started was topical medications. Selective Laser Trabeculoplasty, an alternative, relatively non-invasive treatment, was frequently offered after patients were started on drops. In the LiGHT study, 718 patients with treatment-naïve OAG or ocular hypertension were randomized to SLT or eye drops to assess for quality-of-life outcomes, clinical efficacy (measured by intraocular pressure and required additional treatments), and cost.

Key Points:

• SLT was effective at lowering eye pressure – at 6 years, 69.8% of patients with SLT were at goal IOP without any drops or incisional surgery, though 90% of those patients required SLT twice
• There were no significant differences in quality-of-life measures at either 3 or 6 years between the two groups
• Initiation with SLT was found to be significantly more cost effective than initiation with eye drops

The LiGHT study proposed a new paradigm in the treatment of glaucoma and ocular hypertension, aiming to offer SLT to any newly diagnosed patient. It showed rather good clinical efficacy and reduced societal costs for SLT, though quality of life measures were not different. All in all, SLT is an effective measure to treat many types of glaucoma, and could have the added benefit of being less costly.