November 23, 2022

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

In this week's issue

  • A new study identifies frail patients as most at risk for developing endogenous endophthalmitis.
  • The prevalence of early stage AMD is higher than previously thought.
  • Vigorous physical activity increases your risk of developing central serous chorioretinopathy.
  • D-ARN! Visual outcomes for acute retinal necrosis remain poor, although moderate success has been demonstrated with modern surgical techniques.

Frailty and endogenous endophthalmitis: What are the odds?


Back pains and bacterial strains… getting older is not easy. Endogenous endophthalmitis (EE) is a rare complication of septicemia with an estimated incidence of 0.04% - 0.4%. Frailty, a general term used to describe physical and mental decline, can often predict systemic decompensation to a greater degree than age or comorbidities alone. Using the National Inpatient Sample from 2002-2014, a retrospective, population-level study sought to understand the impact of frailty (defined by a frailty index from the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator) on EE among inpatients with bacteremia. Of 9,292 inpatients with bacteremia who subsequently developed EE, 2,102 (22.6%) were categorized as being frail due to ≥1 frailty-defining feature, most notably malnutrition. The odds of developing EE were 16.7% higher for frail patients when controlling for a host of comorbidities and demographic factors. Additionally, frail patients had increased odds of inpatient mortality, methicillin-resistant Staphylococcus aureus, gram-negative bacteremia, candidemia, longer length of stay, and increased hospital costs. It is theorized that malnutrition, the most common frailty-defining feature in this study, may contribute to endophthalmitis via breakdown of the blood-retinal barrier. Therefore, ophthalmologists should be aware of key frailty-defining criteria to properly evaluate for EE.

Prevalence of AMD in the United States

JAMA Ophthalmology

AMD is everywhere, but not all AMD is causing vision loss! There is a wide spectrum from early AMD (largely asymptomatic) to late AMD (exudation and atrophy which are vision threatening). Nonetheless, age related macular degeneration (AMD) is a leading cause of vision loss in the United States. The prevalence of AMD has not been evaluated in the United States in over 10 years and the prevalence of early-stage AMD has not been consistently measured in the past. This research team performed a bayesian meta-regression using various data from the Centers for Disease Control and Prevention’s Vision and Eye Health Surveillance System to estimate the prevalence of early and late-stage AMD in the American population. Overall, they found that 18.34 million (95% uncertainty interval (UI): 15.30-22.03) people in the US over 40 have early stage AMD, with a crude prevalence of 11.64%. Similarly, there were 1.49 million (95% UI: 0.97-2.15) in the US over 40 with late-stage AMD, with a crude prevalence of 0.95% (95% UI: 0.62-1.36). The prevalence of AMD varied substantially by age group, race, ethnicity, and county. The authors conclude that there is a higher prevalence of early-stage AMD than reported in previous literature, while the prevalence of late-stage AMD is similar to previous studies. This may be a result of earlier/routine use of imaging technology such as optical coherence tomography.

Association between vigorous physical activity and central serous chorioretinopathy

American Journal of Ophthalmology

Do you even lift, bro? Central serous chorioretinopathy (CSCR) is characterized by serous detachment of the neurosensory retina. In order to determine if sudden elevations in blood pressure increase choroidal vasculature perfusion and contribute to CSCR, researchers performed a multicenter case-control study comparing the physical activity of 105 patients with CSCR and 105 healthy controls using a standardized questionnaire. Physical activity was then quantified based on energy expenditure using the metabolic equivalent of task (MET) metric with the Ainsworth Compendium of Physical Activities as a reference for categorizing activities as vigorous. Vigorous physical activity was measured in 63.5% of patients in the CSCR group compared to 26% of patients in the control group (P = .0001), with the most frequent physical activities being weight lifting, bicycling, and running in both groups. Furthermore, the odds ratio of CSCR associated with moderate to high physical activity was 5.58 (95% CI 3.01-10.69, P = .0001). It is possible that along with other stressors, vigorous physical activity results in the body producing more cortisol/corticosteroids, which have been linked to CSC.  While future studies might provide a better understanding of this relationship by utilizing more reliable data collection methods and considering other confounding factors, the results of this study highlight a significant association between vigorous physical activity and CSCR.

Uveitis & Oncology

Visual prognosis is bleak for patients with acute retinal necrosis-related retinal detachments 

Ophthalmology Retina

Even modern medicine has its limits, and that’s particularly true for this infection. Acute retinal necrosis (ARN) is a rare viral panuveitis with an estimated incidence of 1 case per 2 million people per year. Caused by the Herpesviridae family, ARN presents with rapidly progressive necrotizing retinitis, occlusive vasculitis, and secondary retinal detachment (RD) in 63% of eyes. Despite advances in diagnostic and surgical techniques, visual prognosis of ARN-related RD remains poor with little consensus on predictive clinical parameters. In this single-center, retrospective, consecutive case series, Albini et al. analyzed 34 eyes with polymerase-chain reaction-positive ARN who underwent small-gauge pars plana vitrectomy (PPV) with or without scleral buckle (SB) for ARN-related RD. Single-surgery anatomic success rate was 63.6% and associated with significantly better visual acuity (VA) compared to eyes with recurrent RD (p<0.01), however functional outcomes were still poor at final follow-up (mean VA ~ 20/640) regardless of SB use. Female sex and zone 1 (or nearing the fovea and optic disc) involvement were predictive of recurrent RD, whereas older age and worse initial VA were associated with lower VA at one year. Although limited by its small sample size and retrospective design, this study demonstrates that moderate single surgery anatomic success can be achieved with small-gauge PPV for repair of ARN-related RD. 

Lens Landmarks

Trick or treat? While eyeball injections and lasers give off haunted house vibes, patients may be in for a treat! The DRCR I evaluated the safety and efficacy of intravitreal ranibizumab with prompt or deferred laser and intravitreal triamcinolone with laser as compared to laser alone for the treatment of diabetic macular edema over 1 year.

Key Points:
  • Regardless of laser timeline, ranibizumab treatment led to significantly improved visual acuity.
  • Treatment with either ranibizumab or triamcinolone in addition to laser led to a decrease in mean central subfield thickness on OCT compared to laser alone.
  • While ranibizumab may uncommonly lead to retinal detachments or endophthalmitis secondary to injection, it is an overall safe treatment option  
DRCR I demonstrated that treating patients with intravitreal ranibizumab + prompt or deferred laser is a safe and efficacious option to improve visual acuity and decrease central subfield thickness in patients with diabetic macular edema. This study introduced anti-VEGF agents as a leading option for the treatment of diabetic macular edema.

Question of the Week

A 70 year-old woman presents with forward protrusion of the eyes, decreased extraocular eye movements limited by pain, blurry vision, foreign body sensation, double vision, and lid retraction. Her symptoms began months ago and has progressively worsened.

Work-up includes an MRI that demonstrates the following:
What is the most likely diagnosis?

A. Nonspecific orbital inflammation
B. Neurofibromatosis
C. Thyroid Eye Disease
D. Optic Nerve Glioma

Keep scrolling for answer or click here

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Quiz Answer: C
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