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October 12, 2022


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

In this week's issue

  • The COVID-19 vaccine may be associated with flares of anterior noninfectious uveitis.
  • Male neonates are screened and treated more often for retinopathy of prematurity.
  • Written post-ED instructions for ophthalmologic conditions improve follow up in most people.
  • Ocular ultrasound may be a reliable way to measure elevated intracranial pressure.

Noninfectious uveitis may be linked to the COVID-19 vaccine

Ophthalmology

Coronavirus and uveitis, avoiding one may increase your risk for the other! COVID-19 is one of the leading health concerns worldwide, which is now being combatted with various vaccines. Previous studies have posited an association between the COVID-19 vaccine and ocular complications, however, no direct association with uveitis had been found. This study retrospectively analyzed 2,602,557 people who received their first COVID-19 vaccine. Noninfectious uveitis (NIU) was defined as inflammation that occurred or worsened within 21 days of the vaccine that required corticosteroids. 188 episodes of NIU were found within 21 days of vaccine administration, with an estimated age and sex adjusted standardized incidence ratio of 1.41. The attributable risk decreased following the second dose as compared to following the first dose (0.86 versus 1.12, per 100,000 vaccinations). Over 90% of this was anterior uveitis that was treated topically. It should be noted that small study effect size and sample size preclude ability to determine cause and effect relationships. This study shows that while the BNT162b2 mRNA coronavirus vaccine is effective in preventing the spread of and lethal complications of COVID-19, it may lead to an increased risk of NIU.

The male-to-female treatment ratio in retinopathy of prematurity

JAMA Ophthalmology

Retinopathy of prematurity: yet another battle of the sexes? Retinopathy of Prematurity (ROP) is due to aberrant neovascularization, and leads to increased risk of retinal detachment and blindness that is largely preventable with procedural intervention. Prior anecdotal evidence has suggested that male neonates are at greater risk of developing ROP than females, and so this study aimed to evaluate A) if a sex-related difference is truly present, and B) if present, whether it is due to physiologic related differences or differences in screening between the sexes. This systematic review and meta-analysis gathered data from 316 studies meeting inclusion criteria, yielding information on patients treated for ROP with anti-VEGF therapy, laser photocoagulation, or cryotherapy. Of the 31,026 patients treated for ROP, 55% were males and 45% were females. 38 studies reported sex-related differences in screening of ROP, with more males (53%) being screened than females (47%). There was no difference in the proportion of screened males and screened females that received treatment. This study shows that more males are treated for ROP than females, largely due to the fact that more males meet the screening criteria. Further studies should be directed at why more male neonates meet ROP screening criteria than females.

A nightmare in the ED?

American Journal of Ophthalmology

The emergency department (ED) can be a spooky place, according to Dr. Glaucomflecken. Ophthalmologists are consulted for a variety of ocular conditions ranging from self-limiting to vision- or life-threatening emergencies. A study from the Jamaica Hospital Medical Center looked to identify factors that affect the likelihood of follow-up after ED visits for ophthalmic complaints. Patients in the control group were only given verbal instructions. Patients in the intervention group were given verbal and written instructions, telephone calls, and a mailed letter if there was no response to the calls. They analyzed outcomes such as overall follow-up rates and rates by patient subgroup. Patients in the intervention group were significantly more likely to follow up (68.8% vs. 42.9%, p<0.001). Nearly all subgroups exhibited significantly improved follow-up with the intervention, with the exception of patients aged 18-29, patients with diagnosis severity class III, patients with no insurance, patients with hospital financial aid, patients paying with workers’ compensation, and patients with an unknown employment status. It may seem intuitive that more interventional instructions were more successful in getting patients to follow-up, but this study highlights the importance of proper counseling and discharge to ensure patients of all age or demographic subgroups receive proper ophthalmic follow-up. 

Ultrasonography of the optic nerve subarachnoid space to estimate intracranial pressure

British Journal of Ophthalmology

They say the window to the brain is the eye, or at least the stuff around it. Knowledge of intracranial pressure (ICP) is valuable in numerous neurologic and ophthalmologic conditions. Ultrasonography of the optic nerve recently has been proposed as a rapid, non-invasive way to measure ICP; however, consistency and optimal technique remains challenging. In this study, investigators explored whether ultrasonographic measurement of the optic nerve subarachnoid space area (ONSASA) could reliably estimate ICP. This prospective study involved 90 patients who underwent intraparenchymal ICP monitoring for aneurysmal subarachnoid hemorrhage, intraparenchymal hemorrhage, or severe traumatic brain injury. Participants were randomly divided into a training group (n=63) and test group (n=27). Among the parameters measured, including optic nerve diameter, sheath diameter, and ONSASA, ICP most significantly correlated with ONSASA (Pearson’s correlation r=0.953). Using an ICP >20 mm Hg as the cut-off for high ICP, the derived model using ONSASA to predict ICP had a sensitivity and specificity of 1.00 and 0.92, respectively, resulting in a ROC area of 0.960. Further studies with larger cohorts are needed to determine the generalizability of this method, including for patients with ICP > 30 mm Hg as well as the comparison of ocular ultrasound to more standardized methods of assessing ICP (lumbar puncture, MRI, ophthalmodynamometry, or more recently EDI OCT). This method of non-invasively measuring ICP could be a useful adjunct to neuro-ophthalmologist’s armament, especially when ruling in or out elevated ICP which can be both vision and life-threatening in the appropriate clinical context.

Neuro-Ophthalmology 

What can help predict visual prognosis in Aquaporin-4 IgG+ neuromyelitis optica spectrum disorder?

Ophthalmology

What do aquaporins have to do with eye pain or vision loss? Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory demyelinating disease of the central nervous system, with over 60% of patients presenting with optic neuritis (ON). It is well-established that aquraporin-4-immunoglobulin (AQP4-IgG) is a fairly sensitive and highly specific marker for NMOSD, and seropositive NMOSD patients have more severe disease and more frequent relapses than seronegative NMOSD. The poor visual outcomes of patients with NMOSD are generally thought to be associated with more frequent ON recurrences, which cause RNFL and GCL thinning consistent with demyelinating optic neuropathy. Researchers retrospectively examined a cohort of patients who experienced at least one attack of ON and were diagnosed with AQP4-IgG seropositive NMOSD. Mean age of first ON onset was 42.7 years and all were all female. The authors found that worse functional (visual acuity) as well as structural (i.e. RNFL and GCL thinning) outcomes were associated with severity of ON rather than frequency of recurrences. Older age and intracanalicular to chiasmal lesions also seem to be negative predictors of visual outcomes. This is important as early initiation of treatment (i.e. with IV methylprednisone) and long-term immunosuppression may decrease severity of ON episodes and prevent recurrences. This study is very limited by small sample size, homogenous patient population, and short follow up, limiting its generalizability.

Lens Landmarks


Corticosteroids reduce macular edema in patients with retinal vein occlusion? SCORE! The Standard Care vs Corticosteroid for Central Retinal Vein Occlusion (SCORE-CRVO) sought to determine the optimal treatment for vision loss associated with macular edema secondary to perfused central retinal vein occlusion (CRVO). 271 patients from 66 clinical sites were randomized to three groups: observation (n=88), 1mg intravitreal triamcinolone (n=92), 4mg intravitreal triamcinolone (n=91). Participants were retreated at 4-month intervals for 36 months.

Key Points:
  • The likelihood of a 15 letter gain in visual acuity at 1 year was five times greater with 1mg intravitreal triamcinolone (95% CI, 1.8-14.1; P=.001) and 4mg intravitreal triamcinolone (95% CI, 1.8-14.4; P=.001) compared to the observation group.
  • Unlike visual acuity, no significant difference was found in retinal thickness between groups at 12 months.
  • There was a dose-dependent relationship to the need of initiating IOP-lowering medications with triamcinolone (41% in the 4-mg group and 7% in the 1-mg group) compared with the standard-care group (2%).
Overall, the SCORE-CRVO is a landmark study because it led to a major shift in the treatment of vision loss associated with macular edema secondary to CRVO. Prior to this study, there was no proven, effective treatment for this condition and the standard of care was observation. The results demonstrate both 1-mg and 4-mg intravitreal triamcinolone had better visual acuity outcomes over 12 months compared to the untreated natural course of disease. Given the safety profile of the low dose, particularly with respect to glaucoma and cataract, 1-mg intravitreal triamcinolone became the preferred treatment of macular edema in patients with CRVO. Shortly after this study, however, another set of Landmark studies (BRAVO & CRUISE) enlightened us to even more effective treatment options.

Question of the Week

A 29-year old woman presented with acute anterior uveitis. She also reports headaches, joint pain, and frequent painful oral ulcers. A recent pretibial skin biopsy by a dermatologist showed pathology consistent with erythema nodosum and further testing identified the patient as HLA-B51 positive.

Identify the finding shown in the image that occurs in roughly 25% of patients with this condition.
A. Hyphema
B. Hypopyon
C. Peripheral inferior corneal ulcer
D. Silicone oil following retinal surgery



 
Keep scrolling for answer or click here
 

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