December 6, 2022

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

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In this week's issue

  • Primary Baerveldt tube shunt and trabeculectomy with mitomycin C had equivalent IOP after 5 years follow up but tube surgery required more glaucoma medications.
  • No significant difference in tractional retinal detachment rates for patients with proliferative diabetic retinopathy with intravitreal injection only compared to laser only, or 6-month loss to follow-up compared to no loss to follow up.
  • Refractive surgery significantly improved quality of life scores in children with neurodevelopmental disorders.
  • Continuation of prostaglandin analogues following uneventful cataract surgery did not increase the incidence of cystoid macular edema.

Primary tube vs. trabeculectomy five year outcomes 


Standing the test of time…. which glaucoma treatment will succeed. The only known modifiable treatment factor in glaucoma is lowering the intraocular pressure (IOP). While surgical treatment for glaucoma continues to expand, trabeculectomy and a primary tube are currently the most efficacious. However, there remains a debate on which surgery is preferable in low risk eyes. This is a multicenter randomized clinical trial that aimed to compare trabeculectomy with mitomycin C (0.4 mg/ml for two minutes) and tube shunt (350-mm2 Baerveldt glaucoma implant) as a primary glaucoma procedure. The outcome measures were surgical failure, IOP, glaucoma medical therapy, and visual acuity. There was no significant difference in probability of failure after 5 years (P=0.21) or difference in IOP (P=0.52). However, the trabeculectomy group used less glaucoma medications (1.3 ± 1.4) 5 years after surgery while the tube group used more medications (2.2 ± 1.3). Overall, trabeculectomy with mitomycin C and tube shunt produced similar five year outcomes and can both be considered as first line surgical treatment for glaucoma.

Treatment type or loss to follow-up: does either affect retinal detachment rates in proliferative diabetic retinopathy?

JAMA Ophthalmology

Injections, lasers, both, or none? Can any outcome predict the development of tractional retinal detachment? Proliferative diabetic retinopathy (PDR) can result in tractional retinal detachment (TRD), and thus significant vision loss. At present, there is conflicting evidence about the relationship between PDR therapies - intravitreal injections (IVIs) and panretinal photocoagulation (PRP) - with resultant TRD. This case-control study aimed to determine if these interventions or a 6+ month loss to follow-up (LTFU) had effects on TRD rates. The study utilized patients with PDR, and compared those who developed TRD to those who did not develop TRD. In total, 213 TRD patients were matched to 978 non-TRD controls. No difference in odds of TRD were found comparing patients who received IVI with patients who received PRP (aOR: 0.56). Patients who had both treatments had a higher odds of TRD compared to the PRP treated group (aOR: 2.33), and patients who had no treatment had lower odds of TRD (aOR: 0.46). Lastly, there was no observed difference in the odds of TRD between those with LTFU for 6+ months or longer compared to those without LTFU (aOR: 0.72). This study shows there is no increased risk for TRD in PDR patients undergoing IVI treatment or with 6+ month periods of LTFU. As LTFU is still high in PDR patients, we should look to decrease LTFU to mitigate potential vision loss in these patients.

Can refractive surgery improve quality of life for children with neurodevelopmental disorders?

American Journal of Ophthalmology

Can we improve the quality of life of children with learning disabilities by improving their vision? Neurodevelopmental disorders, such as intellectual disability, autism spectrum disorder, and cerebral palsy, affect a significant number of children in the United States. The risk of visual disorders, such as strabismus and refractive error, is increased in this patient population, and about ⅓ of these patients have refractive error. While some of these patients can be managed with spectacles or contact lenses, these interventions do not work for everyone. Failure to intervene on these children can impact their visual development and further hinder their cognitive potential. This prospective interventional case series used multiple validated scoring systems to estimate baseline quality of life and compared these results to post-surgical measures. At baseline, 14 patients demonstrated decreased median eye-related quality of life (QoL), moderate deficiencies in social behaviors, and low adaptive functioning. 6 patients underwent refractive surgery without complication. Post-operatively, 11/11 eyes were within ±1.5 D spherical equivalent. 4/6 patients exhibited clinically significant improvements in QoL scores after surgery. Even in the presence of significant social and adaptive impairments, refractive surgery is associated with clinically significant improvements in eye-related quality of life. Pediatric ophthalmologists play an important role in helping those with intellectual disabilities improve their quality of life and cognitive potential.

Cystoid macular edema following topical prostaglandin analog use after cataract surgery

British Journal of Ophthalmology

It’s all about balancing the risks and benefits…or is it? One complication following cataract surgery is development of cystoid macular edema (CME). While numerous risk factors have been identified, it remains unclear whether topical prostaglandin analogues (PGA), a treatment for glaucoma, increases the risk for CME occurrence when continued post-operatively. In this randomized control trial of 62 individuals with primary open angle glaucoma (POAG) or ocular hypertension (OH) who underwent unilateral cataract surgery, patients were randomized either to continue PGAs (CPGA) or discontinue PGAs (DPGA). By 1 month, both the CPGA and DPGA groups had 4 cases of CME (12.9%) as determined by optical coherence tomography. Increases in central macular thickness did not significantly differ between the groups (CPGA mean 91±114µm; DPGA mean 11±9µm; p=0.212). In addition, by 1 month, IOP in the CPGA group was reduced compared to baseline (-2.0 ± 3.5 mm Hg; p=0.003), but was not in the DPGA group. Limitations of these findings include small sample size and that the fellow eye in the DPGA did not stop medical therapy, which may have affected systemic levels of prostaglandins. Nevertheless, this trial suggests that continuation of PGAs following uncomplicated cataract surgery can effectively lower IOP without significantly increasing CME incidence.


Quantitative eye and pupil tracking as a noninvasive diagnostic alternative of myasthenia gravis 

Journal of Neuro-Ophthalmology

What does eye tracking have to do with myasthenia gravis? The majority of myasthenia gravis (MG) patients (60% to 75%) have initial ocular symptoms that are non-specific. Early recognition of these initial presentations can encourage timely interventions that reduce the burden of morbidity and mortality. Eye-tracking technologies such as video-oculography can help diagnose MG in a noninvasive, technically less demanding, and time-effective manner compared to current diagnostic tests. The tracking of saccadic and pupillary constrictor movements can demonstrate muscle fatigue and recovery in MG patients. Researchers retrospectively examined 32 studies using oculography and 6 studies using pupillometry to diagnose MG. The authors found that intersaccadic, intrasaccadic, and postsaccadic abnormalities, optokinetic nystagmus changes, slow eye movements, disconjugate saccades, and pupillary constrictor muscle weakness can have diagnostic value. The sensitivity of these variables is limited, especially for patients who only present with ocular symptoms. However, this is important as early diagnosis and initiation of treatment may decrease the disease burden in MG patients. Therefore, oculography and pupillometry may be a promising diagnostic test for MG. This study is very limited by small sample size and heterogeneous patient population limiting its generalizability.

Lens Landmarks

Is patience still a virtue when managing ROP? The most common cause of pediatric blindness in the United States is retinopathy of prematurity (ROP), a condition characterized by abnormal angiogenesis following incomplete retinal vascularization in premature infants. Surgical management of ROP involves cryotherapy or laser therapy to avascular retina – however prior to the ETROP study, standard of care involved waiting to intervene until risk of retinal detachment or macular folds reached ≥ 50% (“threshold” ROP). ETROP was a randomized control trial to determine whether early ablation for “prethreshold” ROP (risk ≥ 15%) would improve visual acuity and structural outcomes compared to conventional management.

Key Points:
  • At 9 months of age, early peripheral retinal ablation significantly reduced unfavorable visual (from 19.5% to 14.5%, p=.01) and structural outcomes (from 15.6% to 9.1%, P < 0.001).
  • Further analysis revealed a new clinical algorithm for early prethreshold ROP treatment: Type 1 ROP (Zone I, any stage ROP with plus disease; Zone I, stage 3 ROP without plus disease; or Zone II, stage 2 or 3 with plus disease) should be managed with immediate intervention, while Type 2 ROP (zone I, stage I or 2 ROP without plus disease or zone II, stage 3 ROP without plus disease) should be closely monitored.
  • Patients were followed until 6 years of age and the structural benefits of early treatment persisted for eyes with high-risk prethreshold ROP; however, visual acuity benefits were only present for eyes with type 1 ROP.

ET-ROP was a landmark study that established the current treatment guidelines for ROP, demonstrating the structural and visual benefits of early intervention for eyes with type 1 ROP. However even with early treatment, 65.4% of eyes still developed visual acuity worse than 20/40, indicating the fundamental limitations in ROP management.

Question of the Week

A 68-year-old woman presents with a progressively enlarging mass in the right inferior orbit. Evaluation of the lower eyelid reveals thickening of the inferior fornix with follicular enlargement as seen in the image below.
What is the most likely diagnosis?

A. Diffuse large B-cell lymphoma
B. Sebaceous carcinoma
C. Hodgkin lymphoma
D. Mucosa-associated lymphoid tissue (MALToma)

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Quiz Answer: D
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