October 26, 2022

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

In this week's issue

  • Smoking intensity was associated with faster visual field loss in primary open-angle glaucoma.
  • Google search results for “eye doctor near me” underrepresented ophthalmologists compared to optometrists in most US counties.
  • Cataract surgery in uveitis was found to have low rates of intraoperative complications but frequent postoperative complications including uveitis flares.
  • In the ACCORD-eye study, roughly two-thirds of eyes of individuals with diabetes achieved good visual outcomes after cataract surgery.

Smoking increases risk of visual field progression in POAG


Yet another reason to encourage smoking cessation. IOP is the only modifiable risk factor for the development and progression of glaucoma, although a new study reveals tobacco use may be the second. Researchers assessed the effect of smoking on rates of progressive visual field damage in 511 eyes from 354 patients with glaucoma. In this retrospective cohort study, participants were followed for over 12 years and divided into three groups: never smokers, mild-moderate smokers (0-20 pack-years), and heavy smokers (>20 pack-years). The risk of progressive visual field loss for heavy smokers was 2.2 times the risk of never smokers. Additionally, in a 3-way interaction analysis among 1) smoking intensity, 2) age, and 3) time, aging increased the risk of the effect of heavy smoking on visual field progression. Smoking intensity may be an independent prognostic factor of POAG progression – if recognized, this would have important health care implications in both glaucoma screening and clinical management. Study results suggest smoking cessation advice and support would be effective preventive intervention and may decrease progression in high-risk populations.

Analysis of Google search results for eye doctors in the United States

JAMA Ophthalmology

Need an eye doctor? Let me Google that for you! As the United States population grows older, the need for vision care continues to rise. Optometrists have been increasingly perceived as a cost-effective alternative to ophthalmologists for accommodating growing demand. However, appropriate boundaries for optometry scope of practice must be set to ensure care quality and patient safety. This policy-level process is driven, in part, by public perception of the field. To investigate the purview of ophthalmologists in the United States, a research group analyzed Google search results for the query “eye doctor near me” in 2,955 counties nationwide. For each county, the group manually determined the proportion of ophthalmologists and optometrists represented in the search results. These proportions were compared to provider data from the US Centers for Medicare and Medicaid Services (CMS). Google search results estimated the mean proportion of ophthalmologists to be 4,726.97 of 16,345.93 (28.91%) eyecare providers. This estimate was significantly lower than the proportion generated from CMS data, which included 15,778 ophthalmologists amongst 41,945 (37.58%, χ2 < 0.001) eyecare providers. These data suggest that, on average, ophthalmologists are underrepresented in Google search results. Because the visibility and priority of search results are both indicative of and influenced by public perception, the authors hypothesize this underrepresentation may obfuscate the role of ophthalmologists and optometrists in the delivery of eye care. Increasing website traffic through search engine optimization is one tool ophthalmologists may use to advocate for their practice, functioning to improve brand visibility while educating and helping patients understand differences between eyecare providers.

Keeping an eye on uveitis during and after cataract surgery

American Journal of Ophthalmology

It’s all fun and games until someone gets recurrent uveitis! Cataract surgery is a routine procedure that is frequently required in patients with uveitis, due in part to both primary disease process and the use of corticosteroids as common therapy. While cataract surgery remains a safe and effective option for these patients, special consideration must be paid to the intraoperative and postoperative complications that might arise. In this retrospective cohort study, researchers analyzed 471 eyes of 371 patients who presented to a public hospital in New Zealand between 2008 and 2020 with uveitis and underwent subsequent cataract surgery of the same eye. Key data included additional intraoperative procedures as well as postoperative complications. The most common additional procedures performed were lysis of posterior synechiae (32.3%) and use of iris hooks (19.1%). The most common postoperative complication was a uveitis flare, presenting in 266 eyes (56.5%). Uveitis flare most frequently presented within 2 years after cataract surgery, with 195 eyes (41.4%) reporting a flare during that time. While certain aspects of the retrospective design may limit this study’s reach, results from this study complement those in prior literature that endorse careful monitoring for postoperative complications and relapse of uveitis in patients undergoing cataract surgery.

Visual acuity outcomes after cataract surgery in type 2 diabetes

British Journal of Ophthalmology

ACCORD-ing to this study, visual outcomes in individuals with diabetes continues to be crummy. This retrospective case-control study analyzed visual outcomes after cataract surgery and identified predictors of good visual outcome in those with type 2 diabetes using the Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized control trial and ACCORD-Eye study. Overall, 67.1% achieved a good visual outcome with higher level of education, clinical center network (highest Veterans Affairs, OR 3.46), better preoperative VA (20/20+, OR 10.59), and bilateral cataract surgery (OR 1.55). Notable factors associated with visual outcomes included preoperative VA and diabetic retinopathy, but not HbA1C, underscoring that while certain ocular measures may help to evaluate visual potential, systemic parameters may not be as valuable. One limitation of this study is the use of clinical trial data which may reduce generalizability of the results.

Can a second surgical incision balance out astigmatism from the main wound?


Are two incisions better than one? Surgically induced astigmatism (SIA) from a surgical main incision can detrimentally affect postoperative quality of vision. This 12-month, prospective, RCT of 108 eyes sought to compare SIA between one- (55 eyes) and two-site (53) phacotrabeculectomy. All subjects underwent trabeculectomy with a superior scleral flap; the one-site group received a 2.8-mm wound under the scleral flap, and the two-site had a temporal 2.8-mm clear corneal incision. One-site had a mean astigmatic vector power that decreased from pre-op (0.89) to 12-months post-op (0.78, p=0.018), while two-site had no significant difference from pre-op (0.97) to 12-months post-op (0.96, p=0.94). However, the mean change in astigmatic vector power for one-site group (0.81) and two-site (1.11) were not statistically different (p=0.032). Additionally, post-op corneal topography in the one-site group revealed higher prevalence of superior flattening (54.5% at 3 months, 58.2% at 12 months) compared to superior steepening in the two-site group (60.3% at 3 months, 64.1% at 12 months). This study demonstrated that SIA is not statistically different between phacotrabeculectomies with one or two main incisions. One-site may be preferable in cases of with-the-rule astigmatism, while two-site for against-the-rule.


Vitreomacular traction: to treat or not to treat?

Ophthalmology Retina

Sometimes the best way to deal with a clingy (vitreous) is just to give it time! The vitreous is a collagenous gel that fills the posterior chamber of the eye and attaches to the retina at various locations, including the macula, optic disc, and pars plana. As the eye ages, the vitreous gradually liquifies and shrinks – eventually pulling away from the inner retina in an event known as a posterior vitreous detachment (PVD). If the vitreous is too tightly adherent to the macula during this separation, vitreomacular traction (VMT) can occur, causing distortion of the foveal surface. While some cases of VMT require surgical intervention, others can occasionally be managed with observation in hopes of spontaneous release. In this retrospective consecutive case series, 436 eyes with VMT were graded based on OCT findings and managed by initial observation for at least 3 months. Diagnostic OCT characteristics included distortion of the fovea (grade 1 VMT) with intraretinal cysts (grade 2 VMT) and subfoveal fluid (grade 3 VMT). VMT remained stable in 50.9%, 55.2%, and 28.8% of eyes respectively while spontaneous release of VMT occurred in 25.0%, 14.5%, and 5.8% of eyes (median observation period: 290 days, 570 days, 790 days). Although limited by its retrospective nature and variable follow up intervals, this study demonstrates that VMT has a generally stable clinical course and can be initially managed by observation in certain groups.

Lens Landmarks

A study for the AGES! In the AGIS study, 789 eyes with medically recalcitrant open-angle glaucoma (OAG) were randomized to two different treatment sequences: argon laser trabeculoplasty - trabeculectomy - trabeculectomy (ATT; n=404) and trabeculectomy - argon laser trabeculoplasty - trabeculectomy (TAT; n=385). The primary outcomes include visual field (VF) & visual acuity (VA), and other outcomes included intraocular pressure (IOP), surgical complications, time to treatment failure, additional medical therapy needed.

Key Points:
  • Compared to TAT, ATT provided less overall loss of visual acuity (VA) and visual field (VF) in black patients, whereas white patients with TAT had less overall VA & VF loss.
  • Less visual field loss was associated with an average IOP of 14mmHg or less during the first 18 months after the first surgical intervention, as well as for eyes with IOP of 18mm Hg or less for all study visits.
  • Younger age and higher IOP were related to decreased ALT efficacy.
Overall, the AGIS study is a landmark study because it studied varying sequences of surgical and procedural interventions in glaucoma patients. The key conclusion at the time surrounded the different optimal treatment algorithm for white and black patients. However, given the development of treatment options such as SLT and MIGS since the study, the outcomes of the study should be considered in the context of the times of the study.

Question of the Week

A 4-month-old boy presents with leukocoria of the right eye. A B-scan is performed which shows multiple characteristic foci of intense hyper-reflectivity of the posterior pole. Which of the slides below is most consistent with this child's B-scan findings?
A. Slide A
B. Slide B
C. Slide C
D. Slide D

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Quiz Answer: B
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