February 8, 2023

The most important ophthalmology research updates, delivered directly to you.
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In this week's issue

  • Alcohol consumption increased relative risk of exfoliation glaucoma in patients that consumed greater than 3.6 drinks per week compared to non-drinkers.
  • Tricyclic antidepressants, insulin, and class III antiarrhythmics were shown to be more commonly used in patients undergoing surgical removal of cataracts.
  • A case series on fungal endophthalmitis after cataract surgery from contaminated visco showed early IOL removal provided the best outcomes.

Think before you drink: Alcohol consumption & exfoliation glaucoma


Could there be a link between peer pressure and ocular pressure? A prospective study following 195,408 healthcare workers over a period of 28-38 years highlighted the association between increased alcohol consumption and risk of exfoliation glaucoma/suspect (XFG/XFGS) status. The relative risk of XFG/XFGS among individuals with cumulative average alcohol consumption ≥15g/day was significantly higher than nondrinkers (RR: 1.55; p=0.02). Additionally, individuals with long-term (4 years before XFG/XFGS diagnosis) average alcohol intake of ≥15g/day had significantly higher risk of XFG/XFGS than nondrinkers (RR: 1.65; p=0.002). Of note, when compared to nondrinkers, greatest risk of XFG/XFGS development was seen with consumption of ≥3.6 drinks/week of liquor (RR: 1.46; p=0.01), with the same amounts of wine (RR: 1.30; p=0.15) and beer (RR: 1.26; p=0.40) posing lower risks. This study also describes folate deficiency as a possible etiology of this phenomenon and brings attention to the importance of social history in patient care, even among patients who are healthcare workers as well.

Outbreak of fungal endophthalmitis after cataract surgery in South Korea

JAMA Ophthalmology

A sticky situation. Ophthalmic viscosurgical devices (OVDs) such as sodium hyaluronate are utilized to protect ocular structures and maintain the anterior chamber during cataract surgery. Contaminated OVDs, while uncommon, can result in difficult-to-manage post-operative infections. In such cases, batch contamination may result in widespread infection of patients following cataract surgery. This retrospective case series followed patients diagnosed with fungal endophthalmitis following cataract surgery with contaminated sodium hyaluronate viscoelastic material. Fungal endophthalmitis was diagnosed in 281 eyes, cultures were performed on 260 of them, and direct fungal presence was observed in 103 of them. 89 of these fungal presences were due to Fusarium species. Patients presented with vitreous opacity (n=212), IOL infiltration (n=143), and ciliary infiltration (n=55). Following treatment with antifungals and/or vitrectomy +/- IOL removal, visual outcomes improved from 20/120 to 20/45 in 228 eyes. Early IOL removal yielded the best outcomes in post-cataract surgery fungal endophthalmitis. Worse outcomes were due to delayed reporting, short course antifungals, and not removing the IOL and lens capsule.

Evaluation of systemic medications associated with surgically treated cataract among US adults

American Journal of Ophthalmology

Which drugs are culprits for cataracts? While we all learn that systemic corticosteroids are a risk factor for cataract formation, the association of lens opacification with other commonly prescribed medications is controversial. This retrospective cross-sectional study analyzed ~15,000 patients from the National Health and Nutrition Examination Survey (NHANES) database to determine if there were any associations between systemic medications and development of cataract that needed to be treated surgically. Authors identified 20 drug categories with significant associations when controlling for age, gender, ethnicity, education level, and income level. After further controlling for health-related behaviors (smoking status) and comorbid conditions (diabetes mellitus, hypertension, dyslipidemia, cardiopulmonary disease), 8 medications remained statistically significant. The drug categories with the highest odds ratios (OR) were tricyclic antidepressants (OR, 2.21, P=0.001), insulin (OR, 2.13, P<0.001), and class III antiarrhythmic agents (OR, 2.00, P=0.004). Other notable drug classes included SSRIs, calcium channel blockers, loop diuretics, and nutritional supplements. All 8 drug categories demonstrated a dose-response relationship with surgically treated cataract. Interestingly, sex hormone combinations in women reduced the risk of having cataract extraction (OR, 0.011, P<0.001). While this study did not address causation, it may facilitate the development of more effective prevention methods for cataract formation.


Outcomes of tocilizumab treatment for giant cell arteritis from a single neuro-ophthalmology practice

Canadian Journal of Ophthalmology

How much steroid is too much steroid? The combination of tocilizumab (an IL-6 inhibitor) and a steroid taper is effective in maintaining clinical remissionIn patients with giant cell arteritis (GCA). This has been previously shown in the Giant Cell Arteritis Actemra (GiACTA) trial. However, the duration of tocilizumab effect after discontinuation is unknown. Researchers retrospectively reviewed 79 GCA patients at a single-neuro ophthalmology center that were either treated with 1) prednisone 1 mg/kg per day tapered by 10 mg/month, or 2) prednisone 1 mg/kg per day tapered by 10 mg every 2 weeks + 162 mg/0.9 mL tocilizumab weekly or biweekly. Not surprisingly, patients taking both steroid and tocilizumab received a lower cumulative steroid dose and shorter length of steroid therapy. The tocilizumab group did not have inferior disease recurrence or adverse event outcomes. This study design required a nearly 4x increase in the steroid exposure compared to patients of the GiACTA trial, which can be attributed to differences in tapering protocols. This study is notable in showing non-inferiority with tocilizumab, yet it lacked a large sample size and generalizability. 

Lens Landmarks

In the alphabet soup of corneal transplant options, which surgery is best? At the time of the DETECT trial, Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) was the more common surgery used for endothelial keratoplasty, owing to the newness and lack of clear evidence of superior outcomes for Descemet Membrane Endothelial Keratoplasty (DMEK). The DETECT trial sought to provide level 1 evidence to support the expanded use of DMEK. They randomized 50 eyes to DMEK/DSAEK (25 each) to undergo these surgeries by 2 well-trained surgeons at 2 institutions, and sought to assess visual and surgical outcomes.

Key Points:
  • DMEK led to improved BSCVA at 3, 6, 12 months (1.5 lines, 1.8 lines, 1.4 lines, respectively), all with statistically significant levels of improvement
  • There was a non-statistically significant increase endothelial cell loss with DMEK compared to DSAEK (215 fewer cells/mm2at 12 months, P = 0.051)
  • There was no statistically significant increase in adverse events, though the study may have been underpowered to assess for such differences
Overall, the DETECT study provided much needed evidence to support increased use of DMEK as a superior form of endothelial keratoplasty (EK). Before the DETECT trial, DMEKs accounted for less than 15% of EKs, and by the end of 2021, the number of DMEKs and DSAEKs completed in the US were approximately equal.

Question of the Week

A 24-year-old woman with type 1 diabetes and a past history of diabetic retinopathy presents with decreased vision and multiple new floaters in both eyes one week after an otherwise uncomplicated cesarean section. Examination revealed bilateral vitreous hemorrhages in the setting of proliferative diabetic retinopathy during pregnancy.
Which of the following statements below regarding diabetic retinopathy (DR) in pregnancy is true?

A. Patients who are diagnosed with gestational diabetes are at an increased risk for developing DR during pregnancy

B. Patients with diabetes who develop DR during pregnancy (without prior diagnosis) have a low rate of spontaneous postpartum regression.

C. Women with diabetes mellitus type I are at higher risk for progression to DR during pregnancy than those with type II.

D. Patients with severe DR prior to conception have a lower risk of progression of disease during pregnancy

Keep scrolling for answer or click here

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Quiz Answer: C
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