April 5, 2023

The most important ophthalmology research updates, delivered directly to you.
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In this week's issue

  • Areas in the United States with healthcare provider shortages only weakly correlate with eye care providers supply.
  • A new study highlights the epidemiological patterns and mechanisms of Intimate partner violence-related ocular injuries.
  • A meta-analysis reveals that antihypertensives have heterogeneous effects on IOP and glaucoma depending on class of medication.
  • Patients with delayed-onset RD after PVD typically had better VA than those with early-onset RD while no differences were seen in anatomic outcomes.

Real World Ophthalmology: Tell Me Your Secrets Virtual Conference

Real World Ophthalmology is designed to elevate careers of young ophthalmologists and trainees - join us for our virtual meeting on Saturday April 15! Featured sessions include career topics that aren’t covered in training (business management, clinical pearls), the ability to meet and learn from an incredible lineup of speakers (Stephen McLeod, Michael Chiang, 7 academic chairs, and 70+ more leaders in the field). Plus opportunities to nominate colleagues for awards, submit posters to the Poster Hall of Fame, and win prizes! This is a can’t miss opportunity to enjoy all of the benefits of a high-yield conference for FREE and from the comfort of your own home. 

Register today because space is limited! Registering also gives you exclusive access meeting content for 90 days and early bird invites to our in-person networking events at the major meetings.

Access to eye care in the United States


Where oh where have the ophthalmologists gone? Greater than 7 million people in the U.S. are living with diminished visual acuity and as this number continues to increase, equitable access to eye care is imperative. The United States Department of Health and Human Services determines health provider shortage areas (HPSA) through a population-to-physician ratio. HPSA ratios have been determined for primary care, but their applicability to eye care is unknown. The purpose of this cross-sectional study was to determine the HPSA ratio applicability to eye care providers (ECP) and if a new 2-step model that took into account the catchment area would create a more accurate model. 72,735 census tract-level sociodemographic data were analyzed from 2014-2018 and demonstrated a weak correlation between HPSA and ECP density (r=-0.18) or visual impairment (r=0.38) with less than 54% of census tracts in the bottom 25% for ECP density also as HPSAs. Furthermore, census tracts in the top 25% vision impairment were only HPSAs 58% of the time. ECP accessibility issues were identified in residential areas that were rural, poorly educated, uninsured, and over the age of 65, while primarily white and male areas had greater access to care. Overall, this study shows that HPSAs are only weakly correlated with eye care providers and the new 2-step approach using FCA score could help better identify areas where eye care is needed.

Patterns & mechanisms of intimate partner violence-related ocular trauma

JAMA Ophthalmology

Intimate partner violence (IPV), a serious cause of traumatic ocular injury. More than 10 million people in the US have experienced IPV. A previous study found that 68% of battered women were hit in the face with 45% experiencing direct eye damage. Serious visual sequelae from these events include retinal hemorrhage, globe rupture, and orbital fracture. Ensuing vision loss may lead to mental health issues, further degradations in the quality of life and loss of independence. ICD-10-CM codes from the National Trauma Data Bank (NTDB), the largest US database of hospital trauma cases, were used in this retrospective cross-sectional investigation of epidemiological patterns of IPV-related ocular trauma. The NTDB submissions were made up of 62.3% female (n=1618) and 37.7% male (n=980) contributions, and patients had a mean (SD) age of 45.2 (18.4). Orbital fractures (n=1364, 37.1%), eyelid and periocular contusions (n=949, 25.8%), and direct eye and orbit injuries (n=731, 19.9%) made up the majority of the presenting injuries. Women were more likely to sustain injuries at home, be admitted to level 1 trauma centers, and test positive for alcohol during screening, while men were more likely to test positive for drug use during screening. Social determinants of health like sex, race, age, and socioeconomic position are all strongly correlated with IPV. It is essential to create screening guidelines that may recognize ocular trauma survivors from populations at risk for IPV in order to support and treat survivors of trauma.

What is the relationship between systemic antihypertensives and intraocular pressure?

American Journal of Ophthalmology

Should ophthalmologists have a say in their patient’s blood pressure medication? The effects of systemic antihypertensive medication on intraocular pressure (IOP) and glaucoma are not well understood and studies on this topic have been inconsistent. This meta-analysis included 10 studies examining the association between systemic antihypertensive medications and glaucoma or IOP. Beta blockers were associated with a lower odds of glaucoma (OR = 0.83, 95% CI: 0.75, 0.92, 7 studies, n=219,535) and lower IOP (β = -0.53, 95% CI: -1.05, -0.02, 3 studies, n=28,683). Calcium channel blockers (CCBs) were associated with a higher odds of glaucoma (OR=1.13, 95% CI: 1.03, 1.24, 7 studies, n=219,535), but were not correlated with IOP (β = -0.11, 95% CI: -0.25, 0.03, 2 studies, n=20,620). There were no consistent associations between ACE inhibitors, angiotensin receptor blockers, or diuretics with glaucoma or IOP. While additional randomized clinical trials are needed to fully understand this association, this study suggests that patients with both systemic hypertension and a family history of glaucoma may benefit from beta blockers, as they may be protective against glaucoma.

Repair of early vs delayed-onset rhegmatogenous retinal detachment after acute posterior vitreous detachment

British Journal of Ophthalmology

The sooner the better - or maybe not? Posterior vitreous detachment (PVD) is a well-known risk factor for developing rhegmatogenous retinal detachment (RD). RDs may present simultaneously with PVD, or may occur weeks to months afterwards and are secondary to vitreous traction on the retina. Presently, little is known regarding how functional and anatomic outcomes differ for repair of PVDs that cause RDs acutely or in a delayed fashion. In this single-center retrospective study, patients with delayed RD (≥42 days onset after acute PVD, n=70) were compared to sex and age-matched patients who presented with concomitant PVD + RD regarding single surgery anatomic success (SASS) at 3-months post-repair that did not require additional retinal reattachment procedures. At 3-month follow-up, no significant difference in SASS was detected between the delayed-onset (82.9%) and the early-onset (80%) groups. The delayed RD group had fewer eyes that presented macula-off compared to the early RD group (42.9% vs. 65.7%). Visual acuity at time of RD diagnosis was significantly decreased in the delayed-onset group (logMAR 0.51 vs. 1.04), but was better at post-op months 1 and 3 (p=0.005 and 0.041, respectively). No significant differences in visual acuity were detected during subsequent follow-ups. While retrospective, this study did not find significant difference in long-term functional or anatomic outcomes after repair of delayed RDs compared to early-onset RD following PVD.


MRI signal intensity varies along the course of the normal optic nerve

Journal of Neuro-Ophthalmology

It’s a bird! It’s a plane! No, it’s optic neuropathy! Patients with optic neuropathy often need an MRI to identify if there is enhancement of the optic nerve. However, the different etiologies can present with varying patterns of optic nerve enhancement, and these varying patterns can be further complicated by reviewer interpretation. Researchers retrospectively obtained data from 75 patients at a single institution who underwent an MRI brain for oculomotor nerve motor palsy. A single neuroradiologist performed the optic nerve intensity measurements on non-fat-saturated pre-contrast T1 axial, post-contrast fat-saturated T1 axial, and post-contrast fat-saturated T1 coronal images. Results showed that signal intensity ratios of the optic nerve were significantly higher in the prechiasmatic segment compared to the mid-orbit segment for both pre- and post-contrast T1 images, with a mean difference of 19.6% and 14.2% respectively, with this difference being significant on pre-contrast images only. These results indicate that prechiasmatic optic nerve enhancement is easier to see both with and without contrast as compared to and mid-orbit optic nerve enhancement, which has implications for picking up more subtle posterior optic neuropathies. Limitations of this study include small sample size and lack of generalizability. 

Lens Landmarks

Oral vs topical antifungals for corneal ulcers - MUTT ado about nothing? Following MUTT I, in which topical natamycin demonstrated superior efficacy compared to topical voriconazole, the Mycotic Ulcer Treatment Trial II was designed to determine the benefit of oral voriconazole in addition to topical antifungal regimens in cases of severe mycotic keratitis. 240 patients from 6 clinical sites in Nepal and India were randomized to the oral voriconazole treatment group (n=119) and the control, placebo group (n=121); both received topical natamycin and topical voriconazole.

Key Points:
  • Oral voriconazole did lead to a statistically significant reduction in the rate of corneal perforation or need for therapeutic penetrating keratoplasty (HR 0.82, 95% CI, 0.57-1.18, P=0.29)
  • No significant improvement in the mean BSCVA of the oral voriconazole group after 3 months of follow-up
  • A total of 58 adverse events (48.7%) were recorded in the PO voriconazole arm vs. 28 adverse events (23.1%) in the placebo group
Overall, the MUTT II demonstrated that oral voriconazole did lead to an appreciable decrease in the rates of perforation or need for therapeutic penetrating keratoplasty. in fact, its use was associated with increased risk for adverse events. Given the drug’s high-cost profile as well, adjunct oral voriconazole was not recommended in the treatment of mycotic keratitis after this study.

Question of the Week

A 5 day-old male patient is referred for evaluation of "fleshy masses" on the lateral aspect of both corneas. On physical examination of the child, you also note small skin tags on the right cheek and preauricular area. Spine films revealed the following (see image):
Based on the patient’s presentation, which of the following findings is least likely to be associated with this patient’s diagnosis?

A. Hemifacial microsomia
B. Duane Syndrome
C. Eyelid colobomas
D. Alagille syndrome

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Quiz Answer: D
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