November 9, 2022

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

In this week's issue

  • Alkaline phosphatase and lactate dehydrogenase are key predictors of long-term survival in metastatic choroidal and ciliary body melanoma.
  • Smaller optic cup morphology may increase risk for optic disc edema during spaceflight.
  • Retrospective study finds 77% of eyes ultimately developed glaucomatous optic neuropathy after a uveitis diagnosis.

Determinants of long-term survival in metastatic choroidal and ciliary body melanoma

American Journal of Ophthalmology

Primary ocular melanoma, or uveal melanoma, has poor overall survival after metastases. Uveal melanoma can affect the choroid, ciliary body, or iris and is highly metastatic if not caught early. Drs. Carol and Jerry Shields pioneered the TFSOM-DIM mnemonic (“To Find Small Ocular Melanoma Doing IMaging”), which uses specific criteria seen on multimodal imaging to catch suspicious choroidal lesions that are high risk of transforming to malignant melanoma. T for tumor Thickness greater than 2 mm on ultrasonography, F for subretinal Fluid on optical coherence tomography, S for Symptomatic vision loss 20/50 or worse, O for Orange pigment on fundus autofluorescence, M for Melanoma hollow on US, and DIM for DIaMeter > 5 mm on fundus photography. Without early intervention, these lesions can quickly become metastatic. A retrospective cohort study of 330 patients from Finland and 290 patients from Italy looked to build a prognostic model that predicts long-term survival in metastatic choroidal and ciliary body melanoma. An alkaline phosphatase or lactate dehydrogenase level >2X the upper normal limit essentially precluded long-term survival, defined as survival >42 months. Other robust predictors were distant metastasis-free survival >42 months (OR 4.09-4.64), followed by age <60 years (OR 3.23), absence of symptoms (OR 4.19), and largest diameter of the largest metastasis <30 mm (TMN M1a; OR 3.05). These results allow providers to improve counseling of patients with newly diagnosed metastatic uveal melanoma, and prevent overestimation of survival outcomes for this deadly disease. 

Out of this world: optic nerve size and disc edema during spaceflight 

JAMA Ophthalmology

Does space flight affect different sized nerves differently? It has been observed that 70% of crew members who complete long-duration space missions develop optic disc edema, as measured by peripapillary total retinal thickness (TRT). This disc edema is part of a larger syndrome called spaceflight-associated neuro-ocular syndrome which can lead to vision loss and is increasingly relevant as longer expeditions to Mars and the moon are planned. The objective of this study was to identify factors associated with space travel related optic disc edema. In this retrospective cohort study, 31 International Space Station crew were analyzed with pre- and post -flight data including OCT measurements of the peripapillary TRT region. Metrics of optic nerve crowding were also assessed given theorized relationships with NAION. Space flight increased peripapillary TRT from 392 uM to 430 uM (p < 0.001). Greater individual changes in peripapillary TRT were associated with smaller preflight cup volume (-62.8 uM), cup depth (slope -0.11 uM), and cup width (slope -0.03 uM) (p < 0.05 for all).  Smaller optic cup morphology may be related to optic disc edema, allowing for identification for crew at greater risk during space flight missions in the future.

Conversion of ocular hypertension to glaucoma in patients with uveitis

British Journal of Ophthalmology

Uveitis, you’ve GON too far this time. Uveitis is associated with elevated intraocular pressure (IOP), and consequently ocular hypertension (OHT) and glaucoma. This study aimed to describe the presentation, sequelae, and management of uveitis with ocular hypertension. Investigators retrospectively analyzed 139 patients (n=188 eyes) with uveitis between 2008-2018 with either IOP ≥24 mm Hg requiring medical management or with uveitic glaucoma. At initial presentation, 35.1% of eyes had OHT, and the median time to developing OHT was 2.3 months with IOP 34 mm Hg. Glaucomatous optic neuropathy (GON) was present in 26.1% of eyes at time of initial presentation. Progression of OHT to GON occurred in a median of 1.2 years (95% CI 0.7-1.7 years), and 77% of eyes ultimately developed GON. More than 20% of eyes developed central visual field loss due to GON. More than half of eyes (51.6%) required four pressure-lowering drops, and 68 eyes (36.2%) underwent glaucoma surgery. This study indicates a high prevalence of OHT in patients with uveitis, with a rapid progression to GON. Despite aggressive management, many patients with uveitic glaucoma develop visual field loss. Close monitoring of OHT/glaucoma and initiation of early therapy to control IOP must be considered in patients with uveitis.


Symptomatic vs asymptomatic orbital cavernous venous malformations

Ophthalmic Plastic and Reconstructive Surgery

More symptoms, more problems?! Orbital cavernous venous malformations (OCVMs) are benign, well-circumscribed, slowly progressive vascular lesions that are present in 13-30% of the population. They are often found incidentally while investigating other unrelated causes, and may or may not present with mass-like symptoms. This retrospective single-institution study presents the characteristics of symptomatic and asymptomatic OCVMs. 414 patients presented with an OCVM with a mean age of diagnosis of 49 years. 92 asymptomatic patients received their diagnosis on average 10 years later than symptomatic patients (p<0.001). Relative afferent pupillary defects (RAPD; 38% vs 7%) and fundus abnormalities (63% vs 26%) were more common in symptomatic cases. Mean relative exophthalmos was 2.4mm greater in symptomatic cases. The most common presenting symptoms were altered vision (57%), proptosis (55%), orbital ache (21%), and diplopia (13%). Altogether, this suggests that symptomatic cases of OCVM are diagnosed earlier and are associated with higher rates of RAPD and fundus abnormalities. 

Lens Landmarks

Peekabo! Eye See You! The Infant Aphakic Treatment Study (IATS) sought to compare visual outcomes in infants (aged 1-6 months) with a unilateral congenital cataract following cataract extraction surgery and either intraocular lens (IOL) implantation or left aphakic with contact lens usage. Patients then received the same patching therapy and were followed up for up to 5 years.

Key Points:
  • The average visual acuity is not different between the 2 treatment groups.
  • The proportion of adverse events was higher in the IOL group (81%) than contact lens (56%) group.
  • The proportion of additional intraoperative procedures was higher in the IOL group (72%) than the contact lens (12%) group.
  • The percentage of participants included in the adherence analyses did not differ by treatment group.
The IATS showed that with regards to neutral visual acuity outcomes and increased postoperative complications and intraoperative additional procedures, it is better to leave babies who are operated on in the first 6 months of life aphakic and use a contact lens, with the plan to implant an IOL a few years later. A variety of reasons may account for these findings, including a less-traumatic surgery with fewer reoperations need­ed later in life and a better fitted IOL. Still, for patients whom placing contact lenses may be unreasonable, it is worthy to consider lOL placement weighed against the potential risks to avoid amblyopia.

Question of the Week

A 44-year-old female presents with discomfort and blurred vision in the right eye for 4 days. She also reports seeing halos around lights when driving at night. The patient described a history of two similar episodes and review of previous IOP measurements showed a spike to 52 mmHg and 54 mmHg. IOP remained normal between episodes.
What is the cause of the blurred vision and halos present in this patient?

A. Vitreous hemorrhage
B. Corneal edema
C. Fuchs’ dystrophy
D. Uveitis/Iritis

Keep scrolling for answer or click here

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