Current Issue

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In this week’s issue:

• In patients with Fuch’s dystrophy, DSAEK + phacoemulsification achieved the best visual acuity 2 years post-op and lower rates of graft failure than DMEK or DSAEK alone.
• With increasing rates of hospitalizations related to syphilitic uveitis, this condition should not be forgotten on a differential for intra-ocular pathology. 
• A new meta-analysis shows evidence that propranolol may be a good option for both prevention and treatment of ROP.
• While vitreoretinal lymphoma is a challenging diagnosis to make, attention to anterior chamber findings such as specific characteristics of keratic precipitates may help clinch the diagnosis.

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https://podcasters.spotify.com/pod/show/lens-pod/episodes/Newsletter-November-22--2023-e2c847v 

Ophthalmology

To DSAEK or To DMEK for Fuchs dystrophy? 

Does choice of procedure affect visual outcomes? Fuchs endothelial corneal dystrophy (FECD), a bilateral degenerative corneal disease, has become the most common indication for a corneal transplant worldwide. Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) are two widely used corneal transplant procedures. In DMEK, the diseased endothelial cells and the Descemet membrane are replaced by the corresponding healthy tissue, whereas DSAEK adds a thin portion of a donor stroma. This study aimed to compare DMEK and DSAEK with and without concomitant cataract surgery regarding visual acuity 2 years after the surgery. 1,167 participants were recruited from The Swedish Corneal Transplant Register and divided into three comparable groups: DMEK, DSAEK, and phacoemulsification + DSAEK). Visual acuity improved in over 90% of the patients with all 3 surgical procedures. Among patients with matched preoperative corneal status, best corrected visual acuity was 0.1 logMAR in both DMEK and phacoemulsification + DSAEK groups, whereas it was 0.15 logMAR in the DSAEK group (P<0.001). In terms of graft survival rate, the phacoemulsification + DSAEK group was superior. Long-term outcomes were affected less by choice of surgical intervention and more by additional demographic factors including age at time of keratoplasty and previous health history. 

JAMA Ophthalmology

Seeing more Syphilis

Keep an eye out for that Argyll-Robertson pupil! The incidence of syphilis cases is on the rise nationwide, and this trend is reflected in ophthalmology. In this retrospective, cross-sectional study, the researchers aimed to assess the national and regional occurrence of hospitalizations related to syphilitic uveitis in the United States. The study focused on inpatient admissions associated with a diagnosis of syphilitic uveitis between 2010 and 2019. Out of the initial analysis involving 444,674 patients, 5581 hospitalizations related to syphilitic uveitis were identified. Demographic analysis revealed a disproportionate incidence of syphilitic uveitis-related hospitalizations among African Americans (32% of the cohort) and individuals in the low household income quartile (38.8% of the cohort). Notably, the rates of hospitalizations increased over the years, reaching the highest incidence in 2019 at 0.23 per 100,000 population. This data underscores the importance of considering syphilitic uveitis in the differential diagnosis for intra-ocular pathology. However, the study has significant limitations, notably its exclusive focus on hospitalizations with syphilitic uveitis and its inability to account for changes in electronic medical record coding that occurred during the study period.

American Journal of Ophthalmology

Propranolol and its role in the treatment of retinopathy of prematurity

pROPranolol for preemies! Retinopathy of prematurity (ROP) is a potentially blinding disease that affects thousands of infants annually. Normal fetal retinal physiology involves vascularization that begins in utero, which is driven by physiological hypoxia. Premature birth creates early oxygen exposure, which disrupts normal vascular development. There are two stages of ROP, the first being the ischemic stage where blood vessels stop developing. The second stage involves the growth of aberrant blood vessels, which is largely driven by VEGF. The current treatment strategies for ROP involve neutralizing VEGF levels and laser photocoagulation. However, limitations of anti-VEGF therapy include severe adverse effects and the requirement of intraocular injections. Interestingly, it is also known that adrenergic receptors modulate VEGF levels. There is early data that oral, and possibly topical, beta blockers (e.g., propranolol) may be effective in treating ROP. Researchers composed this meta-analysis, involving 8 studies, that looked at the utilization of propranolol in the treatment of ROP. They found that propranolol use was associated with a decreased risk of disease progression in ROP compared to control groups (risk ratio 0.59, p=0.002) as well as a decreased risk of advanced disease (risk ratio 0.42, p=0.006). There was an increased risk of total adverse events (AEs) in the treatment vs. the control group (risk ratio 2.01, p=0.04). However, when looking at individual AEs (e.g., hypotension, hypoglycemia, bradycardia, bronchospasm), the results were not statistically significant for most outcomes. There was no increased risk of death for the treatment group (risk ratio 1.00, p=1.00). Ultimately, propranolol has been used safely to treat many neonatal conditions. It is also a cost-effective and well-tolerated medication. Thus, oral propranolol should be considered as an option for prevention and treatment of ROP in premature infants. 

British Journal of Ophthalmology

What are the anterior segment findings in vitreoretinal lymphoma?

From backstage to center stage…is VRL taking the spotlight?

Early recognition and diagnosis of vitreoretinal lymphoma (VRL) is critical as VRL is a life-threatening neoplasia. As a uveitic masquerade syndrome, diagnosis can be complex and challenging. Posterior segment manifestations have been clearly defined; information on anterior segment features is currently limited. In this retrospective analysis of 188 eyes with biopsy-proven VRL, researchers aimed to better define these characteristics. The most common manifestations were keratic precipitates (KP) (91%), with 60% described as dendritiform and 86% with a whitish-creamy color. KPs were moreso distributed in a diffuse fashion rather than localized (82%). On in vivo confocal microscopy (IVCM), the most common KP morphology was hyper-reflective dots on the endothelium (76% of eyes). Other findings include anterior chamber cell (93%), which may present as more atypical due to documented larger size compared to inflammatory cells in anterior uveitis. This study demonstrates the importance of keeping VRL in the differential diagnosis of uveitis and provides further guidance with regard to anterior segment findings. Researchers noted certain limitations including the retrospective nature of the study and subjectivity between clinicians when describing findings.

JAMA Ophthalmology

SD-OCT: Is progression to geographic atrophy something we foresee?
Deep-learning algorithms for the win! Geographic atrophy (GA) is widely recognized as an advanced stage of dry age-related macular degeneration (AMD). Identifying individuals who will progress to GA is difficult, with no existing markers for progression identified and a low percentage of individuals who progress to GA each year. In this study DeepGAze, a fully automated convolutional neural network-based deep learning algorithm, was used to analyze SD-OCT images of patients with intermediate AMD (iAMD), and predict progression to GA. The Area Under the Receiver Operating Characteristic (AUROC) for prediction of progression from iAMD to GA within 1 year was 0.94 (95% CI, 0.92-0.95; sensitivity, 0.88 [95% CI, 0.84-0.92]; specificity, 0.90 [95% CI, 0.87-0.92]) for the first data set which was used for training and cross-validation. On a secondary independent validation dataset, the model predicted progression to GA with an AUROC of 0.94 (95% CI, 0.91-0.96; sensitivity, 0.91 [95% CI, 0.74-0.98]; specificity, 0.80 [95% CI, 0.63-0.91]). At a high-specificity operating point, simulated clinical trial recruitment was enriched for patients progressing to GA within 1 year by 8.3- to 20.7-fold in the second and third datasets. These results indicate the success of the DeepGAze deep learning algorithm in analyzing large volumes of data and effectively identifying iAMD patients who will progress to GA. In the future, validation using larger datasets and less manual labor could aid clinical decision-making in terms of screening and treatment. 

Wisconsin Epidemiologic Study of Diabetic Retinopathy - 1984

To develop or not to develop… a study on diabetic retinopathy. Diabetic retinopathy is the second leading cause of blindness in the United States. This population-based epidemiological study over 25 years aimed to determine the incidence, prevalence, and severity of diabetic retinopathy and visual impairment and associated risk factors in diabetic patients. The original study was 1980-1982 and there have been six patient follow-ups 1984-86, 1990-92, 1995-96, 2000-01, 2006-07, and 2012-14. There were 996 type 1 diabetic patients and 1370 type 2 diabetic patients who were analyzed for the incidence rate and severity of diabetic retinopathy using stereoscopic color fundus photographs. 

Key Points:

• Diabetic retinopathy was found to be related to longer duration with the disease, high levels of glycosylated hemoglobin, proteinuria, increased diastolic BP, and male sex.
• Incidence and progression of diabetic retinopathy was greatest in those who were younger at the time of diagnosis.
• After 20 years of diabetes mellitus, nearly 99% of patients with type 1 and 60% with type 2 disease demonstrated some degree of diabetic retinopathy.

Overall, after 25 years there have been over 230 reports from the WESDR study to show glycemic control is associated with a decreased risk of diabetic retinopathy and other diabetic complications. It furthermore identified additional risk factors for diabetic retinopathy in those with diabetes.

A 33-year-old woman presents with right-eye redness, itchiness, and watering for several weeks. She has tried artificial tears and over-the-counter topical antihistamines, both of which are not effective. The patient has used contact-lens for 10 years without any problems. Her medications include combined estrogen-progesterone oral contraceptive pills and dupilumab for atopic dermatitis. She denies recent trauma, respiratory infection, or outdoor water activities. Vision is 20/25 OD and 20/20 OS and IOP is 20 mmHg and 15 mmHg. An image of her right eye is shown.

Which of the following is the most appropriate next step?

A. Aggressive lubrication and erythromycin ointment

B. Topical fluorometholone

C. Observation and reassurance

D. Oral doxycycline

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