July 21, 2021

The most important ophthalmology research updates, delivered directly to you.
The Lens Pod is an educational podcast created by medical students in collaboration with experts in Ophthalmology. This week, we learn about ophthalmic emergencies and ED consults with Dr. Grayson Armstrong from Massachusetts Eye and Ear. Find the episode on Spotify or our website. Happy listening!

Atropine & Patching vs Patching Alone for Severe Amblyopia in Children

JAMA Ophthalmology

What can you do when even pirate references don’t convince your pediatric patients to wear their eye patch? ☠️🏴 Poor vision in a single eye, known as amblyopia, results from a breakdown of how the brain and eye work together, with progressive worsening of vision in the weaker eye as the brain ignores its input. Prevention consists of patching the stronger eye; however, efficacy can be limited by poor adherence due to reduced acuity while wearing the patch, discomfort, and preferences of the child. An alternative treatment is atropine eye drops, which function by temporarily blurring the vision in the better eye, forcing the brain to use the weaker eye; however, monotherapy with atropine has been shown to be insufficient for the treatment of amblyopia. In this single-blind randomized controlled clinical trial, researchers compared eye patching with combined atropine and patching (CAPT) for the treatment of severe amblyopia (>20/100 in worse eye) in 108 children age 3-12 years. At 6 months, the CAPT group’s mean improvement was 0.72 (+/- 0.2) logMAR, or 7.2 (+/- 2.0)  lines of improvement, compared with 0.58 (+/- 0.22) logMAR or 5.8 (+/- 2.2) lines in the patching group alone, a statistically significant difference. Adherence to patching was shown to be similar in the two groups suggesting that improvement in outcome can be attributed to the addition of atropine in the CABT group. 

Diabetic Retinopathy: More than Meets the Eye


POV: You are deep into a diabetic screening fundus exam and find yourself counting intraretinal hemorrhages in each quadrant. Stop right there! This could indicate more than just diabetic retinopathy. Researchers from Kaiser Permanente set out to investigate the relationship between retinopathy status and 5-year risk of first time CVA, MI, CHF, and all-cause mortality in 77,376 patients with previously diagnosed diabetes. After controlling for a multitude of factors (demographics, HbA1C, HDL, LDL, blood pressure, and BMI, among others) a multivariate Cox proportional hazard regression revealed a significant association between severity of retinopathy and future risk of CVA, MI, CHF, and death. When compared to patients with no signs of nonproliferative diabetic retinopathy (NPDR), those with minimal NPDR had increased risks of CVA (HR: 1.31, 95%CI: 1.18-1.46), MI (HR: 1.30, 95%CI: 1.15-1.46), CHF (HR:1.29, 95%CI: 1.19-1.40), and death (HR: 1.15, 95%CI: 1.05-1.25). Patients with moderate to severe NPDR or proliferative diabetic retinopathy had even greater hazard rates for the development of these conditions. As the only visible part of the vascular system, signs of diabetes related damage in the eye may be a biomarker for similar damage elsewhere, suggesting a need for the prevention of cardiovascular disease in those with NPDR.

Corneal Transplant Outcomes in Younger Patients with Keratoconus

American Journal of Ophthalmology

It is the best of times, it is the worst of times, it is the time for corneal transplant. In this retrospective cohort study, researchers examine pre-transplant findings and outcomes of corneal transplants for keratoconus in children (<16 years old) compared with adult patients (>17 years old). The study found that children had poorer pre-transplant visual acuity and increased corneal vascularization and ocular surface disease. However, there was no statistically significant difference between the post-transplant outcomes in children versus adults: corrected visual acuity reaching 20/20 (35% in children vs 28% in adults), transplant rejection rate (11% vs 3%), and endothelial rejection (13% vs 10%). Additionally, there is a significant age effect in the Cox regression model for transplant rejection, a 5-year age increase has a 6% decreased hazard of rejection. Young keratoconus patients have excellent transplant outcomes which are comparable to adults and the hazard of rejection was found to decrease. Overall, this study displays no evidence of outcome advantage in delaying corneal transplant until adult years. 

The Potential Utility of Valproic Acid in Minimally Invasive Glaucoma Surgeries

British Journal of Ophthalmology

Thought you could forget about Valproic Acid (VPA) after intern year? You might see it used in glaucoma surgeries in the future! Minimally invasive glaucoma surgeries (MIGS) are becoming increasingly popular as they have reduced complication rates and similar outcomes to traditional glaucoma filtration surgeries. However, a major obstacle is the issue of excessive scar formation after the surgery. The current standard of using Mitomycin C has been highly effective in reducing the immediate scarring response, but not necessarily in the long term. VPA has been recognized as a potential antifibrotic therapy. The authors sought to study the effect of VPA on MIGS in 5 VPA-treated rabbits and 4 phosphate-buffered-saline (PBS) treated rabbits. The study found that the expression of both Col1a1 and Fn genes, two pro-fibrotic genes, in the day 28 rabbit tissues were significantly reduced by 2.02-fold and 1.51-fold on Valproic acid treatment when compared with PBS controls. Additionally, VPA-treated rabbits had blebs that were more quickly detected with less vascularization on slit lamp examination.  This study highlights a need to study a potential new adjunctive therapy to prevent excessive scar formation in MIGS

What affects the price of my Specialty-Specific Disability Insurance?

Sponsored Content

Quick Answer: The longer you wait, the more it’ll cost. Many aspects of securing the lowest cost specialty-specific disability insurance comes down to timing. The younger and healthier you are, the lower your rates will be, and you can save up to 30% just by securing insurance prior to becoming an attending. But the state you secure your initial policy also matters. States like Ohio and Massachusetts offer Unisex rates for certain companies, making it much cheaper for females, while California and New York are by far the most expensive on average. Looking at your options before moving on to your residency training can potentially save you money long term. Twin Oak was created to provide education, expert advice, and a streamlined experience. Twin Oak’s goal is to provide physicians a headache free option to protect their incomes. Check out Twin Oak’s blogs if you want to learn more about all things related to disability insurance or to request a complimentary comparison summary of all your top companies.


Are monocyte white blood cell counts associated with Age Related Macular Degeneration (AMD)?

American Journal of Ophthalmology

When thinking of white blood cells, monocytes certainly don’t come to mind first…. what do those little guys even do? Well, they appear to potentially play a role in the pathogenesis of AMD! In an AJO study, researchers looked at 7,719 participants over the age of 50 and determined the prevalence of any early, intermediate, and late stage AMD. Additionally, they evaluated peripheral monocyte counts in participant’s blood. In a multivariate analysis, the prevalence of any AMD increased with higher blood monocyte count (Odds ratio: 3.49), after adjusting for known risk factors for AMD such as age, and other associated findings such as serum concentration of calcium, and lipoproteins. Participants with a higher monocyte count (≥0.5 vs. 0.1-0.4 × 109/L) had a 1.45-fold increased risk for any AMD and 1.58 fold increased risk for intermediate/late stage AMD. While these findings are just cross-secional associations, they pave the way for future research into the role of the innate immune system in the pathogenesis of AMD.


Uveitis and syphilis: What can OCT tell us?

Ophthalmology Retina

As Rafiki says in The Lion King, you must “look beyond what you see.” This holds true when discussing ocular manifestations of syphilis. Syphilis is a unique disease because it impacts all regions of the eye and can therefore be identified through many modes of ophthalmic imaging. The classic finding on fundus photography includes acute syphilitic posterior placoid chorioretinitis (ASPPC). However, ASPPC may not be present if syphilis is affecting another region of the eye, particularly the uvea. Hu et al. conducted a consecutive retrospective case series of 40 patients (62 eyes) to evaluate the role of OCT in diagnosing uveitis secondary to ocular syphilis. All patients had either intermediate, posterior, or panuveitis secondary to syphilis, with confirmatory serological testing. Almost half (45%) of the eyes had hyperreflective pyramidal lesions of the outer retina and retinal pigment epithelium (RPE) on OCT (SEE IMAGE). Most lesions (68%) resolved after treatment of syphilis. Though ASPPC is pathognomonic for syphilis, 54% of eyes with hyperreflective pyramidal lesions did not have ASPPC on exam. In summary, ASPPC is the classic indicator for ocular syphilis, but it is not always seen on imaging. These authors suggest that hyperreflective outer pyramidal deposits on the outer retina and RPE can indicate uveitis secondary to ocular syphilis and may be used to monitor disease activity.

Question of the Week

A 72-year-old woman with a visually significant left cataract comes into the office for an evaluation for cataract surgery. Best corrected visual acuity is 20/30 OD and 20/50 OS, (she was 20/30 OS at a visit 2 years ago). Slit lamp exam reveals the findings below.
Which of the following complications of cataract surgery is more likely in this patient?
A.    Endophthalmitis
B.    Hemorrhage
C.    Zonular Dehiscence 
D.    Corneal Edema

Keep scrolling for answer or click here

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Quiz Answer: C
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