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December 21, 2022


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

  • Eye-related ED visits have not decreased despite increased access to health insurance after passage of the Affordable Care Act.
  • Many ophthalmologists do not feel comfortable taking parental leave, and most are unfamiliar with their employers’ parental leave policies. 
  • Limited vitrectomy may improve visual function in those with vitreous opacities.
  • DMEK grafts have better 5-year survival and endothelial cell density if no partial detachment or rebubbling occurred, and a standardized DMEK technique reduced rebubbling and graft failure risks.
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Eye have a headache from all of this insurance talk

Ophthalmology

Do all eye-mergencies need the emergency? The Affordable Care Act (ACA) was implemented in the United States in 2010 with the goal of expanding medical coverage and increasing healthcare access for all Americans, particularly those with lower socioeconomic status, women, and minorities. As a result, the number of uninsured individuals in the United States decreased from 48.6 million in 2010 to 28.6 million in 2015. Ophthalmology-specific care is often conducted in the outpatient setting, meaning uninsured patients or those of lower socioeconomic status may have difficulties accessing care. This recent retrospective, cross-sectional study analyzed data from the US Nationwide Emergency Department Sample to compare eye-related Emergency Department (ED) visits before (2010-2013) and after (2014-2017) the ACA was passed. Out of 16,808,343 eye-related ED visits during this time, 45% were non-emergent cases.  There was an initial decline in the incidence of eye-related ED visits in the year after the ACA was mandated (652 to 593 per 100,000), followed by a rapid increase in the following years (659 in 2015 & 747 in 2016 per 100,000). The increase in ED use was greatest among individuals in the lowest income quartile. Despite increasing access to insurance coverage, the ACA mandate did not decrease reliance on EDs for ophthalmic care.

Parental leave policies for post-training ophthalmologists

JAMA Ophthalmology

And the cat’s in the cradle and leave policies may help parents come home soon! Stop-the-clock policies are an approach that some employers use to minimize the potential for negative consequences related to parental leave. Such policies temporarily pause the review period for tenure and non-tenure track faculty, thus preventing leave from appearing as lost productivity. Since stop-the-clock policies were introduced in 1971, even some private practices have incorporated similar policies for their performance review of partner-track ophthalmologists. To better understand the culture surrounding parental leave amongst practicing ophthalmologists in North America, investigators distributed an anonymized survey (n=186) to those in both private and academic practice. Respondents’ comfort with asking for parental leave varied by sex, with more women reporting they would be comfortable taking leave compared to men (74.4% vs 54.5%; P = 0.04). Ophthalmologists’ knowledge of their employer’s leave policy varied by practice setting, with most academic ophthalmologists unsure if they had a stop-the-clock policy for tenure review (74% unsure) and most in private practice reporting no such policy (14.5% yes, 49.3% no, 36.2% unsure). Attitudes regarding stop-the-clock policies did not vary significantly by sex or practice setting; 46% of respondents reported that stopping the clock should be optional, 23% thought it should be required, and 18% reported that such policies should not exist. Although this exploratory analysis did not consider or adjust for potentially confounding effects, the results of this study indicate a need to better investigate and understand the availability, nature, impact, and opinions regarding parental leave policies for practicing ophthalmologists.

Limited vitrectomy of vitreous opacities improves contrast sensitivity

American Journal of Ophthalmology

I can see clearly now - the floaters are gone! Myodesopsia, more commonly discussed in the context of “floaters,” refers to vitreous opacifications ranging from occasional nuisance to severe visual limitation. In patients suffering from vision-degrading myodesopsia (VDM), a reduction in contrast sensitivity function (CSF) is proportional to the degree of vitreous density. Similarly, multifocal intraocular lens implants (MFIOLs) are also known culprits to have the potential to limit CSF and can compound this deficit. In patients unable to tolerate these VDMs, both complete and limited vitrectomy have proven to be valuable solutions. Researchers in this prospective, nonrandomized clinical study utilized 180 eyes from as many participants with symptomatic vitreous opacities to evaluate the vitreous echodensity (VE) and CSF before and after either observation or limited vitrectomy. Results were stratified based upon the type of intraocular lens present: multifocal, monofocal (MIOL), or phakic. Compared to participants that underwent observation, those that elected vitrectomy demonstrated a 68% greater VE (P < 0.0001) and a 31% worse CSF (P < 0.0001) pre-operatively. After vitrectomy, participants experienced a decreased VE of 55%, 51%, and 52% (P < 0.0001) with a 37%, 48%, and 43% improvement in CSF (P < 0.0001) for those with MFIOL, MIOL, and phakic eyes, respectively. While the absence of pre-cataract surgery evaluations and the distinction between different types of MFIOLs limit this study, the results suggest that limited vitrectomy may be a viable option to improve visual outcomes of patients suffering from myodesopsia, including patients with MFIOLs.

Are DMEK complications bubbling up or diminishing with surgeon expertise?

Eye

Reducing rebubble rates! Descemet membrane endothelial keratoplasty (DMEK) has shown better visual outcomes, lower graft rejection, and faster recovery than Descemet stripping endothelial keratoplasty (DSEK). However, DMEK is more technically challenging, posing a higher risk of graft detachment, and there is no standardized technique for graft preparation and implantation. Using a 7-year prospective corneal graft database, this retrospective review analyzed outcomes after rebubbling and graft detachment using a standardized DMEK protocol. Complete attachment occurred in 130 cases (73.9%), while 46 cases (26.1%) had partial graft detachment. While 40 (22.7%) detached grafts self-resolved, 6 (3.4%) required rebubbling (indicated if the center or greater than one third of the graft detached). The rebubbled grafts had greater endothelial cell loss (p=0.018 at 1-2 years; p=0.039 at 4-5 years). Fully attached, partially detached and rebubbled grafts had 5-year graft survivals of 98%, 90%, and 83%, respectively (p=0.020), but BCVA were comparable (p=0.437). Any surgical indication for DMEK other than Fuchs dystrophy had greater risk of rebubbling (p=0.007). The study shows that small peripheral detachments can be observed, and this standardized DMEK protocol had a low rebubble rate without increase in graft failure. 

Retina

Diabetic retinopathy shown to be a valuable, independent biomarker for dementia risk 

American Journal of Ophthalmology

Does retinal health equal brain health? Dementia and Alzheimer’s disease (AD) are serious public health problems, affecting over 46 million people worldwide. While diabetes is a known risk factor for dementia, previous studies have postulated that a similar association can be seen with diabetic retinopathy (DR). In this retrospective cohort study, 536 adults  65 years old with medication-defined type 2 diabetes were followed biennially to monitor for new-onset dementia and/or DR. The presence of DR  > 5 years was strongly associated with an increased risk of all-cause dementia (hazard ratio 1.69, p=0.01) and AD (hazard ratio 1.73, p=0.02), even after adjusting for time-varying measures of diabetic severity (microalbuminuria, long-term glycemia, and estimated glomerular filtration rate). Further adjustment for dementia-related vascular factors, insulin use, and APOE genotype had no effect, indicating that DR may be an important independent biomarker for dementia risk in diabetics. Although limited by its observational nature, this study suggests that further exploration of DR may be valuable in understanding the underlying pathophysiology of AD and dementia.

Lens Landmarks


Victory for the vitrectomy! In this trial, three distinct sub-investigations sought to:
  1. Understand the natural history of proliferative diabetic retinopathy (PDR)
  2. Compare early vitrectomy (1-6 months) and traditional management (late vitrectomy, ≥12 months, or immediate vitrectomy if a retinal detachment occurred involving the macula) in PDR without significant vision loss (VA > 20/400)
  3. Compare early vitrectomy and traditional management in PDR with significant vision loss (VA < 20/800, but not no light perception (NLP)) due to severe vitreous hemorrhage (VH)
Key Points:
  • Overall, patients in the early vitrectomy cohort had better visual outcomes than those in the delayed vitrectomy cohort
  • Patients with Type 1 Diabetes and severe vision loss from VH, monocular patients (regardless of diabetes type), and patients with advanced PDR had better visual outcomes when vitrectomy was performed early
  • No significant difference in visual outcomes was identified when comparing early versus late vitrectomy for Type 2 Diabetics
  • Patients who received panretinal photocoagulation (PRP) had better visual outcome
  • Regardless of intervention, NLP vision developed in 20% of eyes after vitreous hemorrhage
Overall, the DRVS is a landmark study because it highlighted how early vitrectomy can result in significantly better visual outcomes both immediately and long term for patients with Type 1 Diabetes, monocular patients, and those with advanced diabetic eye disease. Beyond removing hemorrhaged blood, vitrectomies relieve traction on the retina and eliminate the scaffolding that promotes new vessel proliferation.

Question of the Week

A 65 year old man presents complaining of worsening diplopia, proptosis, and hypoglobus. Work-up includes a CT scan, which demonstrates the following.
Biopsy and pathological examination of the left lacrimal gland leads to a diagnosis of B-cell Lymphoma. Which of the following are symptoms and/or radiological signs suggestive of this diagnosis? 

A. Putty-like appearance
B. Invasion of orbital bones
C. Quickly progressing proptosis
D. Perineural invasion with associated pain


 
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