Current Issue

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In this week’s issue:

• In patients with rhegmatogenous retinal detachments, 5-FU and LMWH resulted in similar rates of proliferative vitreoretinopathy development compared to standard care. 
• Smartphone based 3-dimensional surface imaging may aid the design of glasses for patients with craniofacial abnormalities. 
• Penetrating canaloplasty may be effective in treating glaucoma secondary to iridocorneal endothelial syndrome. .   

Ophthalmology

Intravitreal 5-FU and LMWH in high-risk patients for proliferative vitreoretinopathy

Can this drug combo be the solution to PVR prevention? Proliferative vitreoretinopathy (PVR) is a major complication of rhegmatogenous retinal detachment (RRD) and a common cause of failed surgical intervention. No standard therapy exists to prevent or treat PVR, although previous studies suggest the efficacy of 5-Fluorouracil (5-FU) and Heparin. This study aims to evaluate if an experimental treatment of 5-FU and low-molecular weight heparin (LMWH) can prevent PVR in high-risk eyes more effectively than placebo. In this randomized, double-blind, multi-center trial, 163 high-risk patients were administered intravitreal Verum at the time of surgery, compared to 162 placebo. Risk was assessed by noninvasive laser flare measurements (≥15.0 pc/ms considered “high-risk”). Similar rates of PVR development were seen in eyes treated with combination therapy of 5-FU and LMWH compared to standard care. The authors admit one limitation is that flare value may not be an effective predictor of high-risk PVR. As such, the true efficacy of prophylactic treatment cannot be assessed. However, the drug was well-tolerated in patients and no relevant safety risks were identified, suggesting the possibility for its involvement in future clinical studies.  

JAMA Ophthalmology

Smartphone 3D imaging to create custom glasses for patients with craniofacial anomalies

Taking selfies may prevent amblyopia! Patients with craniofacial anomalies are at risk for vision loss due to amblyopia as many of the conventional spectacles do not fit. Previously, MRI images of the facial structures have been used to design custom 3D printed spectacle frames for this patient population. However, MRI has limitations based on the child having a scan, no interval growth since the last scan, challenges with imaging reconstruction, and challenges obtaining a scan in a pediatric patient. This quality improvement study investigated the usage of 3-Dimensional Surface Imaging (3DSI), a feature commonly available using the front/”selfie” camera of smartphones, to capture facial anatomy and create custom 3D printed glasses. This was compared to 3D printed glasses designed following MRI imaging of the facial structures. Overall, 20 patients were included. The key anatomic parameters for glasses fit, such as face width, canthal distance, and nasal bridge distance were similar from the 3D printed glasses made from 3DSI and MRI (mean difference 1.47 ±0.79 mm). This demonstrates that smartphone-based 3DSI is a viable option to produce custom frames for patients with craniofacial anomalies, with advantages over conventional MRI imaging including the ease of image acquisition, lower cost, and greater access.

American Journal of Ophthalmology

Penetrating canaloplasty’s role in treating glaucoma due to ICE syndrome

Stop, collaborate, and listen - we’re talking about ICE (ICE), baby! Iridocorneal endothelial syndrome (ICE) is a disorder characterized by abnormal corneal endothelial cell proliferation and migration that has a significant potential to lead to glaucoma. The irregular endothelial cells seen in ICE are capable of contributing to anterior synechiae and fibrovascular membranes at the iridocorneal angle, both of which may result in secondary glaucoma due to obstruction of aqueous outflow through the canal of Schlemm. Penetrating canaloplasty is a surgical technique that creates a pathway from the posterior chamber to the canal of Schlemm allowing direct outflow of aqueous humor. In this prospective, non-comparative clinical study, 29 eyes with uncontrolled glaucoma secondary to ICE successfully underwent penetrating canaloplasty in order to achieve intraocular pressure (IOP) control, defined by IOP between 5 and 21 mmHg. Controlled IOP without medications was termed “complete success” while controlled IOP with medications was termed “qualified success.” From a baseline of 39.5 ± 11.8 mmHg on 2.9 ± 1.0 medications, IOP decreased to 17.7 ± 6.6 mmHg (P < .0001) on 0.5 ± 1.1 medications (P < .001) at 6 months and 16.6 ± 5.3 mmHg (P < .001) on 0.2 ± 0.6 medications (P < .001) at 12 months. While its long-term success requires further studies, penetrating canaloplasty may serve as a promising solution for patients with glaucoma secondary to ICE.

British Journal of Ophthalmology 

Has public health advocacy really decreased diabetic retinopathy incidences?

More proof that advocacy does matter. Over the past 20 years, US public health efforts have aimed at reducing the prevalence of diabetic retinopathy (DR), but there is a lack of robust and up-to-date longitudinal studies assessing disease incidence and outcomes. The Multi-Ethnic Study of Atherosclerosis (MESA) looked at the 8-year incidence of DR through consecutive retinal images of 498 diabetic, regionally and ethnically diverse US adults aged 45–84 years old. Additionally using chi-squared analysis, sample t test and Poisson regression models, progression and improvement of DR, and their associated risk factors (demographics, cigarette smoking, alcohol consumption, antihypertensive and antidiabetic medications, vitals, labs) were analyzed. Approximately one in every five participants with diabetes developed incident DR, but 23% of participants with DR showed improvement in disease severity over an 8-year period. When focusing on the Latino population, the older Los Angeles Latino Eye Study (LALES) showed a 4-year incidence of DR was 34% and progression of DR was 39%, versus the more recent MESA study which showed a 8-year DR incidence of 22.5% and DR progression of 14.9%. Increasingly elevated glycosylated hemoglobin and systolic blood pressure were associated with 28% and 14% increased risk of developing DR over 8 years, respectively. While limited by a small sample size, this study with its more current data demonstrates that DR clinical management has improved in different marginalized communities with a need for continued advocacy towards equitable ophthalmologic outcomes. 

Eye

Lighting a new way to fix refractive surprise!

Can open-access methodologies address refractive errors after IOL implantation? As the population of patients with a history of refractive surgery increases, refractive surprise after cataract surgery will likely increase. The first FDA-approved light-adjustable lens can be non-invasively adjusted up to five postoperative treatments. The study examined a co-managed, open-access method to coordinate between the surgeon and the postoperative adjustments by another ophthalmologist. Sixty-two eyes of 33 patients were implanted with an LAL; 33/62 (53.2%) eyes had prior refractive (REF) surgery, and 22/62 (66.7%) had unknown refractive surgery history. At the final postoperative examination (3-9 months), 35/36 (97.2%) total eyes with emmetropic target saw 20/20 or better and 36/36 (100%) were within ±0.50 D standard error (SE) of plano (mean cylinder of −0.15 ± 0.26 D). Of the REF emmetropic goal eyes, 19/20 (95%) saw 20/20 or better, 20/20 (100%) were within ±0.50 D SE of plano (mean cylinder of −0.17 ± 0.28 D). Of the patients who chose monovision, 25/26 (96.2%) had a binocular uncorrected distance visual acuity (VA) of 20/20 or better and binocular uncorrected near VA of J2. No patients lost any best-corrected VA. This study shows that a co-managed, open-access methodology for LAL refractive adjustments between different ophthalmologists can provide safe and excellent refractive outcomes.

American Journal of Ophthalmology

Surveillance of suspected low-risk small choroidal melanoma not associated with worse visual or systemic outcomes 

One does not simply treat every small choroidal lesion…but what about a small choroidal melanoma? In the absence of pathologic confirmation (via tissue biopsy) or documented lesion growth, small choroidal melanoma (SCM) is a clinically suspected diagnosis defined as a pigmented choroidal melanocytic lesion with a height of 1.0-2.5 mm and maximum basal diameter of 5.0-16.0 mm (COMS Criteria). While immediate treatment of SCM is believed to lower risk of metastasis, that risk is low (0-3%) and may not be worth the potential harms of treating benign lesions with vision-threatening interventions. In this retrospective study, 167 patients clinically diagnosed with SCM were treated either immediately (n=125) or after a surveillance period (n=42) with documented basal growth of at least 1.8 mm/12 months. Using a validated prediction calculator, Singh et al. identified patients with “low-risk” SCM in the immediate treatment group and compared their visual outcomes and survival rates with the surveillance group to see if low-risk SCM could be observed rather than immediately treated. Primary outcomes such as best-corrected visual acuity (BCVA) and loss of <15-letter visual acuity did not significantly differ at 12, 24, or 36 months. Overall survival and metastasis-free survival was also equivalent between the two groups. Although limited by its small sample size and retrospective design, this study indicates that low-risk choroidal melanomas can be safely managed with surveillance to document lesion growth without increasing risk for metastatic death.  

SITE

Do doctors need to suppress the use of immunosuppressants? Corticosteroids had been the mainstay of treatment for patients with severe ocular inflammatory disease despite the known side effects. Many ophthalmologists were resistant to using other types of systemic due to concern for increased risk of malignancy. The retrospective cohort SITE study sought to determine if the use of immunosuppressants for the treatment of severe ocular inflammatory disease had a higher risk of development of malignancy than conventional therapy with corticosteroids.

Key Points:

• The rates of malignancy development between patients treated with corticosteroids (1/207), immunosuppressants after initial treatment with corticosteroids (2/189), and immunosuppressants alone (2/141) were not statistically different (P = 0.35).

This study concluded that the rate of developing malignancy in patients with severe ocular inflammatory disease treated with immunosuppressants was no different than those patients treated with corticosteroids alone. Their results support substituting immunosuppressants for corticosteroids in the treatment of these patients since the latter have become increasingly ineffective and chronic use causes highly unfavorable side-effects.

An 82 year old man returns to your clinic for follow-up. Past ocular history is significant for multiple recurrent chalazia of the left upper eyelid. Today he again has another recurrent chalazion along the left upper eyelid associated with marked asymmetrical blepharitis and conjunctivitis that has been unresponsive to previous treatments. He also has what appears to be some yellow thickening of the eyelid. Wide excision biopsy is performed and pathology results are shown:

What is the most likely diagnosis for this patient’s presentation?

A. Adenoviral conjunctivitis

B. Sebaceous cell carcinoma

C. Cat scratch disease

D. Molluscum contagiosum

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