Current Issue

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In this week’s issue

• OCT thinning predicts glaucoma progression, with cpRNFL more informative in early disease and macular GCIPL becoming more useful in later stages.
• Some red-light therapy devices for myopia may exceed safety limits within standard treatment times, highlighting the need for independent validation.
• Adults with migraine had a significantly higher risk of developing central serous chorioretinopathy over five years compared with matched controls.
• In a multi-country study, IOP readings were influenced by ocular and systemic factors leading to wide individual variation in what constitutes “normal” IOP.

Spotify Link:

https://creators.spotify.com/pod/show/5xxCPPPznB0yONJbNOIC4I/episode/690v3mr4Eo9o4dkpQXxt1X/wizard 

Ophthalmology 

cpRNFL and mGCIPL OCT changes to detect glaucoma progression

Glaucoma detection is not “one size fits all”. Optical coherence tomography (OCT) plays a critical role in detecting and monitoring glaucoma. It is often used to image the optic nerve head and measure the thickness of the circumpapillary retinal nerve fiber layer (cpRNFL), which can detect damage from early disease before visual field changes. However, the macular ganglion cell-inner plexiform layer (mGCIPL) may better reflect changes in advanced disease, and patients with faster rates of mGCIPL thinning have been shown to have a higher risk of developing VF changes. This retrospective study aimed to measure and compare rates of cpRNFL and mGCIPL thinning in glaucomatous eyes with and without VF progression, and included 2464 eyes from 1605 patients with glaucoma. The primary outcome measure included rates of thinning (μm/year) and their association with disease severity and progression. Progressing eyes had significantly faster thinning of both cpRNFL and mGCIPL (-1.02 and -1.04 μm/year, respectively) compared with nonprogressing eyes (-0.41 and -0.41 μm/year, respectively). The effect of cpRNFL thinning was strongest with VF progression in glaucoma suspects and early disease but was not statistically significant in advanced glaucoma. Meanwhile, the effect of mGCIPL thinning was smallest in suspects, increased with worsening disease, and remained statistically significant in advanced disease. Overall, this study shows that cpRNFL may be useful in detecting progression in early glaucoma, and mGCIPL in advanced stages. Disease monitoring should be tailored to the patient's glaucoma severity.

JAMA Ophthalmology

 Red light, red flag: Are myopia devices truly safe?

The same light meant to slow myopia may also carry hidden retinal risks. Red light therapy (also called repeated low-level red light therapy) has quickly become a popular treatment to slow myopia progression in children, especially across Asia. However, the safety of commercially available devices has not been carefully tested, despite growing worldwide interest and reports of possible retinal injury. This laboratory-based quality improvement study evaluated the optical output of four red light therapy devices (Sky-n1201, Future Vision, EyeRising, and AirDoc) using American National Standards Institute (ANSI) safety guidelines. Researchers measured how much light reached the retina and calculated how long each device could be safely viewed before exceeding established exposure limits. Two widely used laser-based devices (EyeRising and Sky-n1201) exceeded ANSI safety limits within just 1-3 seconds, far below the recommended 180-second treatment duration. In contrast, the LED-based AirDoc device remained within safe exposure limits even with prolonged viewing. These findings raise important concerns that some laser-based red light therapies may pose avoidable retinal safety risks, emphasizing the need for independent safety validation before widespread pediatric use.

American Journal of Ophthalmology (AJO)

Migraines may increase risk of central serous chorioretinopathy

You're not serous… Central Serous Chorioretinopathy (CSCR) is a retinal disorder characterized by central vision loss and distortion thought to be related to choroidal hyperpermeability. Migraines cause vascular and autonomic dysregulation and have been linked to retinal conditions, particularly vascular occlusions. Case reports have suggested a link between CSCR and migraines, but this retrospective cohort study is novel in its power, using the vast TriNetX database to evaluate 413,663 propensity-score-matched pairs to investigate this link. The study found that patients with migraine have a significantly increased risk of developing CSCR compared to controls (1.43 vs. 0.51 per 10,000). These results remained consistent across various subgroups, including sex and migraine subtype. No significant differences in risk were associated with various migraine medications, such as topiramate or beta-blockers. The authors suggest that the two diseases may have overlapping pathophysiology of vascular dysfunction, though this requires further investigation. Overall, this study highlights a novel and significant connection between migraines and CSCR risk, and the need for further investigation into the potential shared mechanism between these two diseases. 

Investigative Ophthalmology & Visual Science (IOVS) 

Is “normal” eye pressure really normal for everyone?

Turns out, the number on the tonometer tells only part of the story. Intraocular pressure (IOP) is central to glaucoma diagnosis and management, yet clinicians rely on a single cutoff to define “normal.” However, IOP readings are influenced by ocular anatomy and systemic health, and these factors vary widely across age, ethnicity, and geography. This population-based analysis combined data from five large eye studies across Asia and Eastern Europe, including 17,977 participants (35,199 eyes) ranging from childhood to advanced age, and evaluated ocular and systemic contributors to measured IOP. Higher IOP readings were associated with thicker corneas, steeper corneal curvature, higher systolic blood pressure, diabetes, and longer axial length. After correcting for these factors, the “true” IOP varied between individuals, by as much as 18 mmHg, despite identical measured pressures. A measured IOP of 21 mmHg could reflect a much higher or much lower corrected pressure depending on patient characteristics. This suggests that IOP is not a one-size-fits-all metric. Accounting for ocular and systemic determinants may redefine what “normal” IOP means and improve risk stratification for glaucoma.

Ophthalmic Epidemiology
Geographic disparities in access to glaucoma careCould your ZIP code determine your access to glaucoma care? Glaucoma is a leading cause of irreversible vision loss, and early detection and treatment depend heavily on access to trained eye care providers. This national geographic analysis examined the distribution of glaucoma-specializing ophthalmologists and optometrists across the United States and assessed how access relates to local socioeconomic conditions. A total of 2,183 glaucoma-specializing ophthalmologists and 622 glaucoma-focused optometrists were identified and mapped across 3,143 U.S. counties. 78.61% had no glaucoma eye care providers and only 6.94% had access to both provider types. Counties with both providers had higher median household income, higher educational attainment, and lower poverty rates compared with counties without providers. Additionally, ophthalmologists and optometrists tended to practice in the same counties, leaving large regions without any local glaucoma care and underscoring the challenge of extending access to underserved areas. These findings highlight stark geographic and socioeconomic disparities in glaucoma care, emphasizing the critical role of structural and regional factors in shaping access to vision-preserving care.

Journal: Cornea

AI-driven recipient recognition system for corneal transplantation

AI to help streamline the eye bank. Efficient and accurate donor-recipient matching is critical for successful corneal transplantation, yet current allocation systems rely heavily on manual review and limited clinical variables. This study developed an AI-driven recipient recognition system to assist in prioritizing and matching corneal transplant candidates using structured clinical data. Using a retrospective dataset of corneal transplant recipients, the authors trained and validated machine learning models to classify recipient urgency and suitability based on demographic factors, diagnosis, ocular history, and surgical indications. The best-performing model achieved high discriminative ability for recipient classification, with accuracy exceeding 90% and strong agreement with expert clinical decision making. Feature importance analysis highlighted corneal diagnosis, prior graft failure, and urgency indicators as the most influential variables. When compared with traditional rule-based allocation, the AI system demonstrated improved consistency and reduced misclassification of high-priority recipients. These findings suggest that AI-based recipient recognition may support more objective and scalable corneal transplant allocation, with potential to improve equity and efficiency in eye bank and surgical workflows. Prospective validation and integration with existing allocation systems will be important next steps before clinical deployment.

Descemet Endothelial Thickness Comparison Trial

In the alphabet soup of corneal transplant options, which surgery is best? At the time of the DETECT trial, Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) was the more common surgery used for endothelial keratoplasty, owing to the newness and lack of clear evidence of superior outcomes for Descemet Membrane Endothelial Keratoplasty (DMEK). The DETECT trial sought to provide level 1 evidence to support the expanded use of DMEK. They randomized 50 eyes to DMEK/DSAEK (25 each) to undergo these surgeries by 2 well-trained surgeons at 2 institutions, and sought to assess visual and surgical outcomes.

Key Points

• DMEK led to improved BSCVA at 3, 6, 12 months (1.5 lines, 1.8 lines, 1.4 lines, respectively), all with statistically significant levels of improvement
• There was a non-statistically significant increase endothelial cell loss with DMEK compared to DSAEK (215 fewer cells/mm2at 12 months, P = 0.051)
• There was no statistically significant increase in adverse events, though the study may have been underpowered to assess for such differences

Overall, the DETECT study provided much-needed evidence to support increased use of DMEK as a superior form of endothelial keratoplasty (EK). Before the DETECT trial, DMEKs accounted for less than 15% of EKs, and by the end of 2021, the number of DMEKs and DSAEKs completed in the US were approximately equal.