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February 1, 2023


The most important ophthalmology research updates, delivered directly to you.
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Match Day 2023
It's Match Day! Congratulations to all matching applicants who found out today where they will be training for residency. No matter what the results are, we're so excited for your futures in ophthalmology and beyond! - From The Lens Team

In this week's issue
  • Selective laser trabeculoplasty may be a more effective initial glaucoma treatment than eye drops
  • Over one quarter of US adults age ≥71 years have visual impairment
  • Smoking likely increases the risk for needing surgical intervention in patients with thyroid eye disease
  • Specific chromosomal abnormalities (chr 8p loss, 1p loss, and monosomy 3) were associated with risk of metastasis in choroidal melanoma 

SLT efficacy in treating open-angle glaucoma and ocular hypertension

Ophthalmology

Bringing LiGHT to the treatment of glaucoma and ocular hypertension. The use of selective laser trabeculoplasty (SLT) was approved by the FDA in the early 2000’s, however, it remains unclear if this treatment is superior to contemporary medication regimens. This prospective multicenter randomized controlled trial analyzes the clinical outcomes and health-related quality of life (HRQoL) after 6 years for patients who received either SLT or eye drops for open-angle glaucoma (OAG) and ocular hypertension (OHT). There were 524 patients who completed the 6-year trial, and those who received SLT had better control of their glaucoma compared to those who received IOP-lowering drops. Use of SLT decreased progression of disease and the need for glaucoma and cataract surgery at 6 years. Interestingly, there was no significant difference in HRQoL between groups. Finally, 69.8% of those who receive SLT did not need IOP lowering drops or surgery to maintain their target IOP at 6 years. Overall, SLT is not only efficacious but also provides better long-term treatment and surgery prevention than contemporary medication regimens. 

Prevalence of visual impairment in adults 71 years and older in the US

JAMA Ophthalmology

What happens to your eyes in your 70s? Having updated epidemiological data in the geriatric population can assist with identifying their healthcare needs and inform public health initiatives. The current estimates of vision impairment (VI) in the US are at least 14 years old or based on self-reported survey data so there is a necessity for newer estimates. A survey study with secondary data analysis was performed using the 2021 National Health and Aging Trends Study, which included tablet-based tests of distance, near visual acuity, and contrast sensitivity with habitual correction. The results showed 27.8% of US adults > 71 years had VI, impairment with distance in 10.3%, near visual acuity in 22.3%, and contrast sensitivity in 10.0%. A higher prevalence of VI was associated with older age, less education, lower income, non-White race, and Hispanic ethnicity. This study found more than a quarter of adults 71 years and older had VI, which is higher than previous estimates. Identifying populations at greater risk for VI is invaluable to guide and improve healthcare access. 

Smoking and scalpels in thyroid eye disease

American Journal of Ophthalmology

The smoking gun proves that smoking is sinister for patients with thyroid eye disease! Graves disease, an autoimmune hyperthyroidism, can cause extraocular muscle enlargement and orbital fat expansion. These findings are termed thyroid eye disease (TED) and can be managed with medication or, when more severe, surgery. Several risk factors have been found to influence the severity of disease, with smoking being the preeminent modifiable risk factor. Though the relationship between smoking and TED has been well documented, this study focused on determining the strength of the association between smoking and outcomes of TED. This large retrospective cohort study included 87,774 patients with TED. The cohort contained 19% of patients identified as current smokers, 24% as former smokers, and 57% as never smokers. Orbital decompression surgery was more likely to be performed in current smokers than in never smokers (3.7% vs. 1.9%), strabismus surgery was more likely to be performed in current smokers (4.6%) and former smokers (3.1%) compared to never smokers (2.2%), and eyelid recession surgery was more likely to be performed in current smokers compared to never smokers (4.1% vs. 2.6%). Altogether, smoking was associated with greater risk of surgical intervention in TED. These findings suggest that smoking avoidance and cessation are important to prevent the burden of surgical intervention for patients with TED.   

Is there predictive value in cytogenetic abnormalities found in uveal melanoma?

IOVS

Mind your Ps and Qs – arms of chromosomes, that is. Uveal melanoma usually presents as choroidal (CM) or ciliary body melanoma (CBM). Besides location of origin, these two tumors differ in their malignant behaviors, including spread to distant sites like the liver. In this study, 314 patients (217 with CM and 97 with CBM) from a single cancer center underwent fine needle aspiration biopsy, and cytogenetic analyses were performed for prognostic stratification via probes targeting chromosomes 1, 3, 6, and 8. Patients with CBM had larger tumors, more advanced disease stages, and more systemic metastases. Specific chromosomal abnormalities – chr 8p loss, 1p loss, and monosomy 3 – were found to be independent predictors of metastasis. This study identified specific subgroups of uveal melanoma patients at high risk of systemic spread. If these findings are corroborated, it may be beneficial to prioritize those with these high risk features for regular clinical surveillance.

Global Health & DEI

New Kids on the Block and no ophthalmologists in sight

JAMA Ophthalmology

Silly rabbit, ophthalmologists are for…adults? Over the past several years, a lack of pediatric ophthalmologists has become evident in juxtaposition to the expanding US population. While multifactorial in its nature, the shortage stems in part from a lack of trainee interest (nearly HALF of fellowship positions going unfilled) and existing practitioner geographic distribution. Understanding the relative distribution of pediatric ophthalmologists as related to socioeconomic differences may help address the needs of underserved areas. In this cross-sectional study, pediatric ophthalmologists practicing in the US as of March 2022 were identified using public databases (the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus). Of an identified 1056 pediatric ophthalmologists, none were found to practice in 4 out of 50 states and in 2828 of 3142 counties (90%). Areas with limited access to internet, vehicles, or with populations lacking health insurance were more likely to have 0 compared with 1 or more pediatric ophthalmologists. Given the increased disparities associated with socioeconomic status over the last 15 years, it is important to ensure accurate, publicly available databases as a first step in reaching these underserved communities.

Lens Landmarks

Is more always better? Or, more money, more problems? In this study from 2000, preoperative medical testing was compared to no preoperative medical testing prior to age-related cataract surgery in 19,250 total cataract surgeries. They randomized patients to a no testing and a routine testing group, and assessed for medical adverse events during and within 7 days of the surgery.

Key Points:
  • Routine preoperative medical testing did not reduce the risk of adverse events during or after age-related cataract surgery (cumulative events were 31.3 per 1000 for both groups)
  • Secondary analysis showed no specific benefit when segmenting for age, sex, race, or health status
Overall, the study is a landmark study because it showed that preoperative medical testing before age-related cataract surgery does not provide any significant benefit or improve postoperative outcomes. Further studies and reviews have instead showed that it primarily increases medical costs for patients with age-related cataracts.

Question of the Week
A 62 year old man with a history of dry eyes presents with worsening eyelid drooping. He feels that his eyes have been more irritated than usual. Medical history is significant for hypertension. On examination, gentle traction of the upper eyelid results in the following exam finding:
A further discussion regarding risk factors is obtained from the patient. Which of the following is the most appropriate next step in management?

A. Obtain MRI brain 
B. Referral for polysomnography 
C. Consent the patient for eyelid surgery
D. Referral for echocardiogram



 
Keep scrolling for answer or click here

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