October 5, 2022

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

In this week's issue

  • Longer case lengths, anesthesia other than MAC alone, and younger age are associated with higher odds of emergency room visits within 30 days of cataract surgery.
  • Retinal structural outcomes were good after low and very low-dose intravitreal bevacizumab as initial treatment for type 1 retinopathy of prematurity.
  • Parental leave does not adversely impact performance milestones among ophthalmology residents.
  • Changes in neuromuscular junction development observed before eye opening in albino mice indicate that nystagmus is not solely secondary to poor vision.

A tale of cataracts and bounce-backs

American Journal of Ophthalmology

Somebody call 9-1-1, this lens was just removed in the OR! The number of emergency department (ED) visits in the United States has been steadily increasing in recent years. According to the Healthcare Cost and Utilization Project (HCUP), the ED visitation rate in 2015 was at a 10-year high. Many surgical subspecialties have accepted that ED visits are a key metric in determining quality of patient care. As cataract surgery is the most performed surgery in the US, understanding post-cataract surgery emergency care usage is key to addressing soaring ED usage. This single-institution retrospective cohort study is the first study to examine postoperative ED visits following cataract surgery. A total of 57,656 eyes of 34,246 patients who underwent cataract surgery were included. It was found that 607 patients (1.77%) had 680 ED visits within 30 days of surgery. Patients younger than 70 years old (OR: 1.39), cases longer than 29 minutes (OR: 2.1), or the use of monitored anesthesia care (MAC) combined with retrobulbar or general anesthesia rather than MAC alone (OR: 2.98) yielded higher rates of post-surgery ED visits. The most common ophthalmologic complaints included high intraocular pressure (15.2%), rebound iritis (14.3%), and posterior vitreous detachment (12.4%). Further, self-pay patients were at a higher risk for postoperative ED visits after cataract surgery. Thus, it is important for the surgeon to be aware of these risk factors to alleviate postoperative burden for the patient. Reducing superfluous post-cataract surgery ED visits will not only provide better care for the patient but will also serve to alleviate the burden on emergency care in the US.

Low-dose bevacizumab for retinopathy of prematurity


How low can you go? … How low can bevacizumab go? Intravitreal bevacizumab (IVB), an anti-vascular endothelial growth factor (VEGF) injection, is increasingly favored over laser photocoagulation for treatment of retinopathy of prematurity (ROP). Anti-VEGF offers preservation of peripheral retinal tissue, low cost, high availability, and prior success in treating adult retinal diseases. However, anti-VEGF may have systemic effects lasting weeks after injection and requires long-term monitoring due to chance of ROP reactivation. Researchers sought to better understand the effectiveness of specific anti-VEGF regimens for short-term treatment of ROP. In this multicenter study, 120 infants with type 1 ROP received 2 sequential dose de-escalating treatments of either low-dose IVB or very low-dose IVB. Participants were evaluated for ROP reactivation, need for additional treatment, and 12-month outcomes. Time to ROP reactivation was shorter in eyes receiving very low-dose IVB (mean of 76.4 days) than in those receiving low-dose IVB (mean of 85.7 days). Abnormalities of the cornea, lens, or other locations in the anterior segment were found in only <1%, 3%, and 2% of study eyes, respectively. No significant relationships were found between any 12-month findings and dose of IVB. Thus, ocular outcomes are encouraging for either low-dose or very low-dose IVB for type 1 ROP. However, very low-dose IVB may invite earlier reactivation, which suggests a need for further examination of these drug regimens for treatment of ROP.

Parental leave and its impact on ophthalmology resident performance

JAMA Ophthalmology

Is it ok to take a break? Residents may be hesitant to use parental leave for numerous reasons including perceived stigma or possible effects it might have on their training. A multicenter, retrospective cross-sectional analysis was performed using educational records from 282 ophthalmology residents that graduated between 2015 to 2019 to identify any associations between the use of parental leave and performance. There were no differences found in average OKAP percentiles, research activity, average ACGME milestone scores, or surgical volume between residents who did or did not take parental leave. However, residents who pursued a fellowship were less likely to have taken any leave (OR 0.43; 95% CI, 0.27-0.68; P < 0.001) and residents who went into private settings were more likely to have taken parental leave (OR, 3.56; 95% CI, 1.79-7.08; P < 0.001). These results show performance metrics of ophthalmology residents are not adversely affected when parental leave is used.

Exploring eyesight development: Impaired muscle innervation in nystagmus


What came first – nystagmus or vision deficit? Infantile nystagmus (involuntary, rhythmic oscillation of the eyes) begins early in life and is often accompanied by visual deficits such as albinism. In nystagmus patients, extraocular muscles (EOM) have decreased innervation and abundance of neuromuscular junctions (NMJ), and increased proportion of slow myosin fibers. This paper reports initial evidence using a mouse model to explore when these changes occur. Orbit tissue from Balb/c albino mice and control littermates at postnatal day zero (P0) through adulthood (12 weeks) were immunostained for EOM myosin fibers and NMJs. Embryonic (E13.5) innervation patterns were visualized in animals with GFP-expressing neurons. Initial embryonic EOM innervation by cranial nerves was normal in the albino mice. However, as early as postnatal day P10 albino mice EOMs demonstrated significantly decreased NMJ density, and at P14 onward albino mice had an abnormally increased proportion of slow myofibers in EOMs. This study demonstrates that innervation changes (NMJ density in particular) are present in nystagmus animals prior to eye opening, indicating that nystagmus changes are not solely secondary to poor vision. The strain used will be a valuable model for future studies, as it recapitulates the neuromuscular phenotype in human nystagmus.

Lens Landmarks

Older, wiser, and a little blurrier – must be those cataracts! Cataracts are an incredibly common cause of decreased vision across the world, especially among older individuals. Researchers in Beaver Dam Eye Study set out to gather longitudinal data to better investigate characteristics associated with cataract development in order to shed light on areas of greater social and health care needs. This prospective epidemiologic study utilized census data of 2764 participants living in a rural town in the midwestern United States in order to determine the incidence of age-related cataracts and cataract surgery over a 10-year period. Lenses of participants were photographed and graded according to standardized protocol at baseline, 5 years, and 10 years.

Key Points:
  • In both men and women, 10-year incidence of both cataract (nuclear, cortical, and/or posterior subcapsular) and cataract surgery increased with age.
  • The greatest increase in incidence for nuclear sclerotic cataract was seen in those 55 to 64 years old (at baseline). 
  • Compared to men, women were found to be at increased risk of both nuclear sclerotic cataracts and cataract surgery (P< 0.0001). 
The Beaver Dam Eye Study is a critical piece of literature in the epidemiology of cataract development as it provided long-term data to better appreciate the role of age and gender in cataract progression. Its contributions to the early understanding of the incidence and prevalence of different lens opacities make it landmark study in ophthalmology.

Question of the Week

A 9 year old boy presents to clinic with vision loss in his right eye last week. Physical examination is significant for visual acuity of 20/200 and absent red reflex in the right eye. Fundoscopy reveals retinal hemorrhages and extrafoveal exudation in his right eye. IOP is within normal range. A fluorescein angiogram was ordered and is shown below. 
What is the most appropriate next step in management?

A. Laser photoablation
B. Cryotherapy
C. Enucleation
D. Anti-VEGF therapy

Keep scrolling for answer or click here

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