November 16, 2022

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

In this week's issue

  • Multiuse perioperative mydriatic eyedrops are a reasonable option for cost and environmental waste reduction.
  • High polygenic risk was associated with more rapid structural and functional progression in early primary open angle glaucoma.
  • Physicians who did not maintain board certification had a higher risk of disciplinary licensure actions compared with those who did.
  • Coexistence of reticular pseudodrusen in AMD was not associated with significant impairments in choriocapillaris blood flow or vascular structure.

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Reduce, reuse, recycle: Cost saving multiuse preprocedural eyedrop protocol


Imagine buying your favorite luxury perfume, only to throw out the entire bottle after spraying it once. Reminds you of single-use eye drops, doesn’t it? A recent study investigated the cost associated with the current practice of utilizing single-use mydriatic eye drop and povidone-iodine bottles in adults undergoing ophthalmic surgery or intravitreal injections. Cost savings were calculated using economic modeling comparing the current single-use protocol to a protocol in which mydriatic eye drop and povidone-iodine bottles are utilized across multiple patients before being discarded. The multiuse mydriatic protocol resulted in a 97.1% decrease in number of eye drop bottles used and a subsequent 5-year institutional savings of about $240,000. Similarly, the multiuse povidone-iodine protocol led to a 99.6% reduction in number of bottles and resulting 5-year institutional savings of $41,801. Though numerous studies cite minimal contamination and endophthalmitis rates from multiuse eye drop bottles, patient safety remains of utmost concern when considering a multiuse model. However, the cost-saving and environmental benefits highlighted by this study are substantial and should be considered by practices of all sizes. 

Polygenic risk scores for glaucoma risk stratification

JAMA Ophthalmology

Like in golf, here is another score we hope to keep low. Polygenic risk scores (PRSs) provide a means of risk stratification and prognostication, using personalized genomic data to predict disease phenotype and progression. Within the scope of glaucoma, PRSs have been used to predict age of diagnosis, risk of glaucoma, and the rate of thinning measured by optical coherence tomography. In this study, investigators sought to advance the utility of PRSs in glaucoma management by developing algorithms for predicting progressive visual field loss and peripapillary retinal nerve fiber layer thinning. Structural progression analysis of 1,777 eyes showed those of patients among the top 5% of PRSs had faster peripapillary retinal nerve fiber layer thinning than those in the remaining 95% (mean [SD], -1.64 [1.40] vs -1.36 [1.30] µm/y). Functional progression analysis of 1,563 eyes of patients among the top 5% of PRSs showed greater risk of visual field loss after 5 years compared to the remaining 95% (adjusted hazard ratio 1.5). The results of this study indicate that PRSs may become particularly useful for glaucoma suspects. By identifying asymptomatic patients with concerning exam findings and high-risk genetic profiles, careful monitoring and early treatment may help ophthalmologists abate the development of glaucoma. 

A link between American Board of Ophthalmology certification and physician disciplinary action?

American Journal of Ophthalmology

Boards or bust? The American Board of Ophthalmology (ABO) certifies ophthalmologists who have passed training requirements, an oral exam, and a written exam for 10 years, allowing them to maintain the certificate through a process that emphasizes learning, practice improvement, and knowledge. Physicians who violate practice standards that negatively affect patient care are subject to disciplinary action.  This retrospective cohort study of 9,111 ophthalmologists certified between 1992 and 2012 investigated the relationship between ABO certification and 234 instances of disciplinary action against ophthalmologists during this timeframe as reported by the Federation of State Medical Boards. Ophthalmologists who did not maintain ABO certification were 2.34 times more likely to receive disciplinary action and action of higher severity than those who maintained certification. Additionally, male ophthalmologists were twice as likely to receive disciplinary action as compared to their female colleagues. While future studies can build upon this report by standardizing for years in practice and determining what physician behaviors led to varying severities of action, this analysis highlighted an association between ABO certification and physician disciplinary action. While causation cannot be determined, the results can help encourage ophthalmologists to maintain their ABO certification.

Looking at OCT; Impact of reticular pseudodrusen on choriocapillaris flow and choroidal structure


Remember your biostatistics professor repeating that "correlation does not equal causation"? Well, here's another example! Reticular pseudodrusen (RSD) are a classic feature of age-related macular degeneration (AMD) and are distinguished from classical drusen by their presence above the retinal pigment epithelium (RPE). Some studies have highlighted their potential role as a predictor of progression to the late, neovascular form of the disease as their presence often coincides with loss of choroidal vessels and structural thinning. Currently, the field lacks an understanding of RSD formation and how they might accelerate disease progression. To dissect the observed association of RSD with changes to choroid parameters, 102 eyes from 51 patients with intermediate AMD and bilateral large drusen, were evaluated for the presence of RSD, flow deficits (FD) in the choriocapillaris, and choroidal thickness and vascularity. No significant difference was found in choriocapillaris FD or measures of choroidal structure when eyes with imaging-confirmed bilateral RSDs (n = 47) were compared to eyes without RSDs (n = 55). The authors conclude that their results do not support the hypothesis that changes in choroidal blood flow and structure observed in AMD are caused by RPDs. Limitations to this study include its recruitment of participants from a single center in Australia and the predominantly female (80%) cohort.


Hyaluronic acid versus cyclosporine A in dry eye syndrome

Scientific Reports

Ophthalmologists love (healthy) tears… Hyaluronic acid (HA) and cyclosporine A (CsA) eye drops are commonly prescribed in dry eye syndrome (DES). HA is a natural component of tear film widely used in ocular lubricants. Topical CsA is an anti-inflammatory eye drop with an immunomodulatory mechanism of action. This multicenter, randomized study was designed to evaluate the efficacy of either 1) 0.15% HA, 2) 0.05% CsA plus 0.5% carboxymethylcellulose (CMC), or 3) 0.15% HA plus 0.05% CsA in patients with moderate to severe DES. 438 patients were randomized for one of the three treatments and evaluated at baseline, 4 and 12 weeks. The change in corneal staining score for 0.15% HA from baseline was non-inferior to that of 0.05% CsA. Corneal staining score, tear break-up time, strip meniscometry score, and ocular surface disease index test score improved in all groups without statistically significant intergroup differences. Though longer study times may be warranted, the study findings suggest that 0.15% HA may be equivalently effective as 0.05% CsA in treating moderate to severe DES.

Lens Landmarks

Is age really just a number? The Cornea Donor Study is a multicenter, double masked, controlled trial initiated in 2000 to provide data to eye banks about the outcomes of donor tissue from various aged donors used for penetrating keratoplasty (PKP). The initial data published in 2008 demonstrated no significant difference in the 12-65 and 66-75 donor age groups, with no significant association between donor age and graft success. The updated analysis reports data after 10 years of follow-up.

Key Points:
  • There was no significant difference in the 10-year PKP graft success rate for donors aged 12-65 (77%) compared to donors aged 66-75 years old (71%), p=0.11
  • Higher donor age was associated with lower graft success after the first 5 years (p<0.001), mostly in the donor aged 72-75 group
The results of this study show no difference in the 10-year PKP graft success rates between donors aged 12-65 and donors aged 66-75. Although the grafts from donors aged 72-75 showed lower success rates, this difference was small (success rates for donors 66-71: 87%, vs 72-75: 85%). The authors concluded that the donor pool should be expanded to donors up to 75 years old.

Question of the Week

A 69-year-old white man presents with mild discomfort and reports a gradual decrease in the vision of his right eye over the course of 1 week. His ocular history is remarkable for cataract extraction and posterior chamber intraocular lens (IOL) insertion in this eye 4 months previously. Because of the low-grade nature of the inflammation, topical steroids are begun, and the inflammation responded favorably. After discontinuing the steroids, symptoms return and the patient again presents with a granulomatous anterior chamber inflammation, including a small hypopyon and a mild anterior vitritis.
What is the most appropriate therapy for this condition?

A. Vitrectomy and intravitreal injection of amphotericin
B. Observation
C. Vitrectomy, removal of the IOL, and intravitreal injection of gentamicin
D. Vitrectomy, posterior capsulotomy, and intravitreal injection of vancomycin 

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