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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
Recurrence rates of acute anterior uveitis at a single tertiary center
Lightning may not strike the same place twice, but what about acute anterior uveitis? Anterior uveitis represents the most common type of uveitis and primarily affects working-age individuals. While chronic anterior uveitis has been identified as a risk factor for moderate vision loss (≤20/50), the risk factors underlying recurrence of acute anterior uveitis (AAU) are not fully understood. This retrospective cohort study aimed to identify recurrence rates, risk factors, and rates of moderate vision loss among 2763 eyes diagnosed with AAU at a tertiary care center in New Zealand. The overall ipsilateral recurrence rate was 45.5%, with viral (44.9%), HLA-B27 (43.2%), and idiopathic (38.1%) etiologies having the most frequent recurrence over ten years. The overall contralateral recurrence rate was lower at 27.3%, with different ten-year recurrence rates for HLA-B27 (37.6%), idiopathic (15.2%), and viral (2.0%) etiologies. On multivariate analysis, Māori ethnicity and HLA-B27-related disease were significant risk factors for both ipsilateral and contralateral recurrence. Moderate vision loss was observed in 14.9% of eyes by final follow-up and was associated with a shorter time to first recurrence (odds ratio 0.959). As the largest study of its kind to date, this investigation provides valuable insight into the recurrence of AAU and can help guide clinical management for patients with identified risk factors.
JAMA Ophthalmology
JAK of all trades, master of uveitis? HUMBOLDT clinical trial results
The results are truly HUMBOL(DT)ing…Uveitis is a leading cause of blindness in the US and Europe. It describes intraocular inflammation of the uvea and adjacent structures from infectious or noninfectious etiologies. Of the noninfectious causes, autoimmune conditions including inflammatory bowel disease and sarcoidosis, have known associations that include the activation of the Janus kinase (JAK) signaling pathway and continue to have high morbidity despite attempts to control with steroids and other immune modulating agents. In this double-masked, placebo-controlled, randomized clinical trial, eligible participants with active noninfectious intermediate, posterior or panuveitis were assigned to receive 200 mg of filgotinib (a JAK 1 preferential inhibitor) or placebo for up to 1 year. Of 116 screened participants, 74 were randomly assigned to the filgotinib or placebo group. Although the trial was terminated early, a significantly reduced proportion of participants receiving filgotinib experienced treatment failure by week 24 vs those in the placebo group (37.5% vs 67.6 %). These findings suggest a role for JAK1 preferential inhibitors in the treatment of active, noninfectious intermediate to posterior uveitis; however, given the premature endpoint of the study, additional data is needed to fully assess efficacy and safety.
American Journal of Ophthalmology
Seeing the unseen, when vitreoretinal lymphoma hides in plain sight
Looks can be deceiving. Vitreoretinal lymphoma (VRL) associated with primary central nervous system lymphoma (PCNSL) is an elusive malignancy, and may be completely asymptomatic. Conversely, patients with primary VRL typically present with visual symptoms but are often misdiagnosed as having non-infectious uveitis, resulting in delays in appropriate treatment. The aggressive nature of the disease drives researchers to investigate the asymptomatic subset of VRL cases identified during PCNSL staging. A retrospective cross-sectional study was conducted on 104 eyes from 56 patients with cytologically or molecularly confirmed VRL. Patients were categorized into primary VRL (PVRL), symptomatic VRL associated with PCNSL (PCNSL-S), and asymptomatic VRL with PCNSL (PCNSL-AS). The study revealed that patients with PCNL-AS exhibited better visual acuity compared to those with PVRL (0.11 vs. 0.76 LogMAR, respectively). Additionally, PCNSL-AS patients had lower rates of anterior segment involvement and vitritis. Subretinal infiltration was less common in PCNSL-AS (5%) than in PVRL (28%) and PCNSL-S (40%). Specific ocular manifestations of VRL, such as subretinal infiltrates, retinitis-like lesions, retinal hemorrhages, and macular edema were significantly associated with worse visual acuity in VRL patients. Overall, this study emphasizes the need for advanced imaging techniques and screening protocols to detect VRL early, even in asymptomatic cases, to ensure that these cases are treated with the same level of care as symptomatic cases.
British Journal of Ophthalmology
Non-anterior sarcoidosis-associated uveitis: now that's a mouth full!
What immunomodulatory therapy is most appropriate in sarcoidosis-associated uveitis? There has been little research in determining which immunomodulatory therapy has the best outcomes for sarcoidosis-associated uveitis patients. Researchers conducted a retrospective study of 58 patients with non-anterior sarcoidosis-associated uveitis. Among these 58 patients, 33 patients used methotrexate as their immunosuppressive drug of choice while 16 used mycophenolate mofetil and the remaining 9 used azathioprine. Methotrexate had the longest time until treatment failure with a median time of 34.5 months while azathioprine was second with 16.8 months, and finally mycophenolate mofetil with 8.4 months. In addition, low visual acuity status was seen significantly less often in patients taking methotrexate as compared to the other two immunosuppressive drugs. Overall, this suggests that methotrexate seems to be the more efficacious option with a longer median usage rate and better vision outcomes in non-anterior sarcoidosis-associated uveitis. These findings are critical for developing more robust treatment plans for these patients while also having a better understanding of the differences between treatment options within the same drug category.
Eye
Uncovering eye risks in newborns not meeting ROP screening criteria
Eye spy with my little eye, a study revealing hidden ocular risk factors in newborns? Retinopathy of prematurity (ROP) is an eye disease that presents with abnormal blood vessel growth in the retinas of premature infants. Current screening criteria for ROP include low birth weight and early gestational age, which may be limiting to other prenatal, perinatal, and postnatal risk factors for ROP. A prospective study included 1795 newborns who received universal eye screenings administered within 3 days of birth. Newborns weighing under 2000 g or with a gestational age ≤ 34 weeks were excluded. This study aimed to assess the outcomes of universal eye screenings in newborns not meeting ROP screening criteria and the relationship between perinatal risk factors and various ocular abnormalities. The study showed that retinal hemorrhage was more common after normal vaginal delivery (29.6%) than after lower segment cesarean section (3.3%). Non-retinal hemorrhagic ocular abnormalities at birth (such as ROP, Roth spots, avascular retina, and endogenous endophthalmitis) were observed at a rate of 7.5%, and factors such as prematurity, consanguinity, low birth weight, and systemic abnormalities were associated. This study offers valuable insights into potential risk factors that should be considered for inclusion in targeted eye screening protocols for newborns.
Ophthalmology Retina
Two is better than one, but not for PVR (or RRD). PVR can develop in about 5-10% of patients after surgery for RRD, and PVR can complicate surgical repair and lead to worse visual outcomes. This study involved a multicenter, retrospective analysis of data from 2015-2023 from the Vestrum Health Database to identify cases of PVR after RRD in the fellow eye. The odds ratio for PVR development during 6 months postoperatively was the primary outcome measure. Of 57,264 patients, 11% developed PVR in at least one eye. Among the 50,989 patients who did not develop PVR after their initial RRD, 3% developed PVR in the fellow eye, whereas 10% of the 6,275 patients who had PVR after the initial RRD also developed PVR in the fellow eye. A regression model indicated an odds ratio of 3.42 for PVR development in the second eye, with risk factors including younger age, pseudophakia, and poorer initial visual acuity. Patients with a history of RRD complicated by PVR in one eye are 3.5x more likely to develop PVR in their fellow eye after RRD, suggesting the need for vigilant surgical strategies and potentially prophylactic treatments to prevent PVR in the second eye.
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:
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 35-year-old man presents to your clinic with a chief complaint of blurry vision in his right eye. He tells you that for as long as he can remember, his vision has been worse in the right eye, and he is especially bothered by the glare of lights when driving at night. He super-pinholes to 20/25 in the right eye. Your slit lamp examination findings are shown below.
Based on this finding, you recommend cataract surgery to the patient. However, you explain that his surgery will be complex. How might his surgery be different from a more “routine” case?
A. Cumulative dissipated energy (CDE) will be high
B. Post-operative visual acuity will be significantly limited by amblyopia
C. There is an increased risk of zonular weakness
D. Hydrodissection should be skipped
E. Polishing the posterior lens capsule is a critical step
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