December 1, 2021

The most important ophthalmology research updates, delivered directly to you.

In this week's issue

  • Teenagers with more smartphone use may have more refractive error
  • Less than 3% of individuals receiving intraocular brolucizumab had sterile intraocular inflammation
  • Robot-assisted subretinal drug delivery performed similarly to manual drug delivery
  • Belinostat, an HDAC inhibitor, was effective at treating retinoblastoma in vitro

Watch Your Screen Time: Smartphones and Myopia


Raise your hand if you’ve spent hours of your day scrolling through TikTok. A recent cross-sectional study of 525 teenagers between the ages of 12 and 16 years old was conducted to analyze the effect of smartphone use on myopia. Researchers measured hours of daily continuous smartphone use, along with spherical equivalents of refraction (SER), axial length-to-corneal radius (AL:CR), and time spent outside. Continuous smartphone use (defined as 20-minute episodes without breaks) had a small significant association with worse SER (ß=-0.07) and AL:CR ratio (ß=0.004). However, this was not true among teenagers who spent a lot of time outdoors. Given the wide use of smartphones among individuals of all ages, there may be benefits of taking frequent breaks to interrupt prolonged screen use.

Rate of Intraocular Inflammation with Intravitreal Brolucizumab

JAMA Ophthalmology

A poke in the eye may sound irritating - but is it inflammatory? Brolucizumab is an anti-VEGF antibody that was approved by the FDA in October 2019 for the management of neovascular age-related macular degeneration. An important complication of anti-VEGF and other intravitreal agents is intraocular inflammation (IOI). Due to the recency of its FDA approval, epidemiologic data of IOI in patients using brolucizumab is sparse. To address this issue, researchers calculated the incidence and identified risk factors for IOI and/or retinal vascular occlusion (RO) in patients treated with brolucizumab from two large databases: the Intelligent Research in Sight (IRIS) Registry and Komodo Healthcare Map. The incidence of IOI and/or RO was 2.4% in both databases. Higher risk of incident IOI and/or RO was observed in patients with female sex (3.0%, 95% CI 2.6-3.4%, Komodo Healthcare Map) and IOI and/or RO in the year prior to injection (10.6%, 95% CI 7.5-13.7%, Komodo Healthcare Map). This is similar to other anti-VEGF agents, which have estimated risks of sterile IOI of 0.3% to 2.9% per injection. Providers and patients should be aware of this risk when considering treatment with brolucizumab, especially in patients with a history of prior inflammation.

Robot-Assisted Subretinal Drug Delivery

American Journal of Ophthalmology

Are robots the next frontier in retinal surgery? Surgical precision in modern retinal surgery can occasionally exceed human capabilities, and bioengineering companies have sought to increase the human ability to perform some surgical procedures. In this study, the authors sought to investigate the potential for robotic surgery by assessing the feasibility and safety of robot-assisted subretinal drug delivery in patients undergoing vitreoretinal surgery for acute submacular hemorrhage. They compared robot-assisted to manual subretinal recombinant TPA delivery in a double-armed, interventional, randomized controlled surgical trial in 12 patients with submacular hemorrhage. The PRECEYES Surgical System was used, where the surgeon manipulated the hand-held input motion controller to guide the cannula of the injection system into the injection site. The robotic procedure under local anesthesia was well tolerated by all participants. The surgical outcomes and the BCVA were similar between robotic and manual groups (20/400 vs. 20/800, p=0.14). This was the first human study to assess the use of robotic assistance during retinal surgery. These results are promising, and further research is needed to investigate efficacy and improve patient outcomes.

Intravitreal HDAC inhibitor for treatment of retinoblastoma


Why is it important to check the red reflex in a child? And why is leukocoria so concerning? These could be a sign of a retinal mass such as retinoblastoma (RB). RB is the most common intraocular malignancy affecting children and proper treatment is required to preserve vision. Many medical, chemotherapeutic, and surgical treatment options have been developed and utilized for RB. For recurrent RB vitreous seeds, intravitreal chemotherapy with melphalan-based regimens are standard of care, but they are quite toxic to the retina. Therefore, researchers investigated an alternative drug that could be used for RB vitreous seeds treatment. Histone deacetylases (HDAC) have been well studied in the pathophysiology of RB development and progression. HDAC inhibitors have also been approved for treatment of other cancers, notably T cell lymphomas. In this current study, the HDAC inhibitor belinostat was tested in a series of in vivo pharmacokinetic, efficacy, and toxicity experiments using a vitreous seed and retinal tumor xenograft model in rabbits. Belinostat 350 μg (equivalent to 700 μg in a human eye) was more effective at eradicating vitreous seeds in the model compared with melphalan (95.5% reduction for belinostat vs. 89.4% reduction for melphalan) with relatively minimal retinal toxicity. These findings present an exciting development in the search for effective and less toxic alternatives for intravitreal RB treatments. Unlike other HDAC inhibitors that come in pill form, belinostat is already formulated in a solution that would facilitate its use via intravitreal injections. Future studies should aim to determine the exact molecular mechanisms of this drug on RB cells and clinical trials could directly determine its efficacy in humans. 

Cornea & Refractive Surgery

How medication adherent are cornea patients?


Drop the medication into your eye. Don’t drop the habit. This prospective cohort study investigated patient medication adherence to eye drops that manage their corneal conditions. Medication adherence is a wide-spread issue in healthcare; however, this problem has not been formally assessed in regards to management of corneal disease. A total of 199 patients from February to March 2019 (95% response rate) were surveyed using adapted versions of the Adherence to Refills and Medications Scale (ARMS) and Voils’ Medication Adherence Scale (VMAS). 72% of patients were classified as non-adherent by ARMS and 33% were non-adherent according to VMAS. Older age was associated with higher adherence by both scales. Adherence was not significantly associated with race, sex, education, total doses of eye medications, or primary cornea diagnosis. The authors hypothesize that older individuals schedule daily activities around their medication regimen. This habit may contribute to increased compliance compared to younger patients.


Adult donor methods for frontalis suspension are successful in infants

Ophthalmic Plastic and Reconstructive Surgery

Don’t fret, your kiddos legs aren’t too short for autologous fascia lata use in frontalis suspension! Congenital ptosis can be a disabling condition leading to amblyopia, especially in unilateral cases, or anomalous head positions in bilateral cases. The mainstay of surgical treatment is a frontalis suspension, however the main controversy is choice of the material used in the procedure. Autologous fascia lata (AFL) is considered to be the best choice of material, however this has only been recommended in patients above the age of 3 due to belief that there is not enough material available in shorter legs. Garcia-Cruz et al. performed this retrospective case series study analyzing 12 eyes from patients under the age of 3 who underwent frontalis suspension using AFL, observing for margin-to-reflex distance change, recurrence rates, or donor site complications. In all cases, patients under the age of 3 years had successful AFL use in frontalis suspension with enough graft material, no incidence of recurrence, and no observed complications in graft donor site. As congenital ptosis is a serious condition, prompt surgical treatment can still be performed under the age of 3 without having to use less preferred donor material.

Question of the Week

A 45-year-old male is brought to the ED due to abnormal pupillary findings shown below that was first noticed three hours ago. Upon physical exam, the abnormality is greater in the light than in the dark. 
Which of the following is the best next step?
A.    1% Pilocarpine test
B.    Apraclonidine test
C.    Slit lamp examination
D.    MRI of brain

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