What is all this mess?!
“Take all the courses in your curriculum. Do the research. Ask questions. Find someone doing what you are interested in! Be curious!” – Katherine Johnson, 1918 – 2020
That’s right, Researcher, I’m talking to you. And you too, Eye Doctor. Look at what you both did! What’s this on the floor – giant cell arteritis? And this, what is this, a piece of intracranial hypertension? Clean up your monthly dose of ophthalmic research and present them neatly in a list. And don’t even think about going out to see your friends until you’ve gone through all the key conference and course dates at the end. And wash behind your ears. Go on. Scamper.
Now, in the order that they appear, we bring to you:
NEURO-OPHTHALMOLOGY
Comparison between findings in ‘active’ or ‘healed’ giant cell arteritis
Giant cell arteritis (GCA) is the most common systemic vasculitis in older people and can cause devastating sight loss if untreated. Temporal artery biopsy is often relied upon for diagnosis by ophthalmologists, with a positive biopsy result indicating whether the condition is reported as ‘active’ or ‘healed’. Despite many pathological differences between active and healed arteritis, few studies have examined the differences between these two groups with regard to clinical presentation, treatment, and outcomes. The objective of this study was to look for differences in clinical presentation between patients with healed and active arteritis at the time of biopsy. Retrospective medical chart review of 85 patients found 80% had active and 20% had healed disease according to histopathology. A higher percentage of those with active arteritis had ischaemic optic neuropathy, elevated erythrocyte sedimentation rates, elevated C-reactive protein levels, GCA risk score > 7.5% and higher mean GCA risk calculator scores. Patients with healed arteritis were less likely to have visual manifestations than the active arteritis group. As this research is retrospective in nature and single-site, the authors acknowledge that further multi-centre research is needed regarding correlation of biopsy findings and risk of complications or relapses. – Claire Howard
Presenting features of giant cell arteritis with active versus healed arteritis on biopsy. Sun E, Li X, Gruener AM, et al. NEURO-OPHTHALMOLOGY 2023;47(3):129–35. Taylor & Francis Group
Referral patterns and pathways for intracranial hypertension
The authors present a retrospective case review of individuals with suspected raised intracranial pressure (ICP) over a 12-month period a single tertiary neuro-ophthalmology centre. Cases were categorised into four groups based on examination by neuro-ophthalmology; 1) referred after identification of secondary radiologic finding of intracranial hypertension following a brain scan for any reason, 2) referred with confirmed or suspected papilloedma, 3) referred with confirmed or suspected idiopathic intracranial hypertension (IIH) with or without papilloedema, 4) referred with a cerebral spinal fluid (CSF) leak and concern as a result of IIH. The following was extracted from the medical notes: demographics, neuro-ophthalmology examination details, ocular imaging, referral patterns, type of neuroimaging, final neuro-ophthalmic diagnosis, and final disposition. A total of 247 individuals were identified with suspected ICP from 1262 new referrals. Five percent of these were referred with coincidental radiologic findings of intracranial hypertension. A third of these were started on treatment following radiological findings. Active papilloedema was only identified in 27% of those referred with a diagnosis of IIH. The authors highlight the low predictive value of secondary radiologic finding of intracranial hypertension in identifying active IIH. They argue against the routine practice of a full work up for IIH with coincidental radiologic findings, potentially subjecting patients to unnecessary invasive procedures. The examples given were lumbar punctures (n=14) and treatment with acetazolamide / topiramate (n=10). The majority required no further intervention once the presence of papilloedema had been excluded. Fundoscopy was not attempted in ~50% prior to referral to ophthalmology. The authors do acknowledge the rare possibility of IIH without papilloedema and discuss how this should be approached. Limitations of this study are outlined including the retrospective methodology and inclusion from outpatient settings only, which may underestimate the number of referrals. Referrals enquiring about the presence of papilloedema could be assessed by optometry or general ophthalmology to reduce burden on neuro-ophthalmology services. – Lauren Hepworth
Presumptive idiopathic intracranial hypertension based on neuro imaging findings: a referral pattern study. Aung AB, Chen BS, Wicks J, et al. JOURNAL OF NEURO-OPHTHALMOLOGY 2023;43:55–62. Wolters Kluwer
PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS
Burden of caregiving for children with eye diseases
This review was conducted to examine the existent literature and characterise the psychological impact of caregiving for children with various eye diseases. The factors associated with the burden of caregiving were discussed in the context of each eye disease identified. The review included 28 studies with meta-analysis of seven. Selected studies had 2052 caregivers; 1294 were female. The most common eye diseases were low vision / blindness (39%), congenital cataract (14%), glaucoma (14%), strabismus / amblyopia (11%), retinoblastoma (14%) and others. About 90% used a validated scale to assess burden. The remainder used customised questionnaires or interviews. Results indicated a significant degree of mild depression in caregivers of patients with retinoblastoma, primary congenital cataract and visual impairment. The reported financial burden relating to missed workdays and loss of employment opportunities and social isolation experienced by mothers was found to negatively affect the entire family. There was considerable heterogeneity among the included studies and therefore it was challenging to compare results across the different eye diseases. – Fiona Rowe
Psychological impact of caregiving for children with eye diseases: a systematic review and meta-analysis. Pur DR, Cirone KD, Jordanous Y, et al. JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS 2023;60(3):238-47. SLACK Journals
PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS
Prismatic contact lens correction vs prismatic glasses
The aim of this study was to verify if diplopia could be corrected by applying soft directional prism contact lenses, to compare effectiveness of diplopia correction, comfort and quality of vision with these contact lenses compared to prism glasses. This was a prospective study of patients with vertical and / or horizontal diplopia and small angle strabismus (≤8PD). Prism contact lenses were worn in both eyes with split correction to obtain a good balance of vision. The maximum prism strength was 3.5PD horizontal and 4.5PD vertical with an inferior base. Checks were made at one and six months of contact lens wear. Eight patients were included aged 12–60 years. All had diplopia correction with contact lenses and were orthophoric. None had pain or discomfort and had good correction of diplopia in secondary gaze positions unlike with prism glasses. Best corrected visual acuity remained unchanged. All patients preferred the prism contact lenses over glasses. It was also possible to build in spectacle prescriptions. The limit of the prism strength within contact lenses was 5PD in any axis. However, they advise a maximum of 1.5PD with superior base, 3.5PD horizontal and 4.5PD with inferior base. This option reduces prismatic aberrations significantly in comparison to glasses and is proposed as a useful alternative to prism glasses for a select group of patients. – Fiona Rowe
Application of soft directional prismatic contact lenses to correct diplopia. Parolini B, Penzani R, Pascotto P. JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS 2023;60(3):248-52. SLACK Journals
Association of strabismus with functional impairment in children in the USA
In this study the authors aimed to (1) determine if strabismus is associated with clinically significant functional impairment, (2) identify specific domains of impairment and (3) examine predictors of impairment among children aged 5-17 years. Data were extracted and analysed from the 1996-2015 medical expenditure panel survey in the USA (MEPS) which included 132,819 children aged 5-17 years. Diagnosis of strabismus was in 201 of these children; 49.2% male, 72.4% aged 5–11 and 27.6% aged 12–17 years. 45.5% were white, 4.2% black, 24.3% poor-low income and 43.8% high income. Diagnosis of strabismus was more likely in the younger age group, in those with higher income, those with private health insurance and having ≥ one chronic comorbid disease. Strabismus diagnosis was associated with greater overall functional limitation with nearly two-fold greater odds. Specific domains affected included getting along with mother / father / other children, nervousness, getting involved in sports / hobbies, behaviour at home, and staying out of trouble. The authors conclude childhood strabismus is a burdensome condition that limits full engagement in relationships and activities with greater impairment in older male children in the Midwest US with public insurance cover. They recommend consideration of functional impairment in management discussions. – Fiona Rowe
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Association of pediatric strabismus and functional impairment: a cross-sectional nationwide analysis. Cheng BT, Kim AB, Nadimpalli S, et al. JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS 2023;60(3):268-76. SLACK Journals
RCT of unilateral vs bilateral surgery for lateral incomitance in exotropia
The purpose of this study was to evaluate and compare the surgical outcomes in the management of lateral incomitance with regard to ocular alignment and change in lateral incomitance in cases of bilateral vs. unilateral strabismus surgery. This was a prospective pilot randomised control trial (RCT) with 40 cases having unilateral surgery and 40 having bilateral surgery. Features of the bilateral surgery group were: mean age 19.1 ±7.8 years, 22 males, 18 females, mean preoperative angle 28.8 ±5.1PD, postoperative angle 5.0 ±1.5PD, mean preoperative lateral incomitance 8.3 ±1.6PD, postoperative lateral incomitance 2.8 ±2.4PD and successful outcome 90%. Features of the unilateral surgery group were: mean age 18.5 ±6.8 years, 20 males, 20 females, mean preoperative angle 29.2 ±5.2PD, postoperative angle 5.1 ±1.4PD, mean preoperative lateral incomitance 8.9 ±1.4PD, postoperative lateral incomitance 3.7 ±2.5PD and successful outcome 85%. There were no significant differences between the two groups for these features. There were no cases of consecutive esotropia and the prevalence of lateral incomitance over a period of 12 months was 19.4%. Both surgical options were equally efficacious in reducing the deviation and improving lateral incomitance. This now requires a phase 3 effectiveness trial. – Fiona Rowe
Comparative study of bilateral vs unilateral strabismus surgery in the management of lateral incomitance in exotropia. Anand K, Krishnan A, Kumar P, et al. JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS 2023;60(3):277-81. SLACK Journals
PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS
Randomised controlled trial for large-angle exotropia surgery
The purpose of this study was to investigate single eye, single setting surgical options to correct 80–90PD of exotropia with two options of muscle transplant and suture hang-back recession. There was retention of anatomical limits of 6mm resection for medial rectus and 9mm recession for lateral rectus muscles. This was a prospective randomised controlled trial with angles >60PD, over 18 years of age and no prior history of extraocular muscle surgery. Group 1 included medial rectus resection and transplant-aided lateral rectus recession of median 5mm. Group 2 included medial rectus resection with hang-back suture for lateral rectus recession of median 6mm. Ten subjects were allocated per group with median age of 27.5 years for group 1 and 26.0 years for group 2, preoperative deviation of 87.5PD for group 1 and 85.0PD for group 2, median postoperative abduction limitation of -0.50 for group 1, median surgery time of 38.5 minutes for group 1 and 30.5 minutes for group 1, and -1 for group 2, and net corrected postoperative angle of 81PD for groups 1 and 2. Each group attained 80% successful outcomes. The authors conclude that both procedures could address 60–90PD by one eye surgery. Hang-back procedures had surgical technical advantages and ease of procedure, and therefore were preferred. – Fiona Rowe
A pilot randomised clinical trial comparing muscle transplant versus hang-back recession in extra-large angle exotropia. Pujari A, Modaboyina S, Thangavel R, et al. STRABISMUS 2023;31(3):159–65. Taylor & Francis Group
RETINA VITREOUS AND UVEA
Clinical predictors of proliferative sickle cell retinopathy
Sickle Cell Disease (SCD) is an inherited disorder resulting in production of Haemoglobin S (HbS), which aggregates in conditions of hypoxia, acidosis or hyperosmolarity. This leads to vascular stasis, thrombosis and ischaemia. The authors present a cross-sectional study (45 consecutive patients) aiming to identify clinical, laboratory and / or ophthalmological predictors of proliferative sickle cell retinopathy (PSR) to define a screening strategy to identify patients at a higher risk of developing eye complications. The patients were split into two groups, those with non-proliferative retinopathy (NPSR) and those with PSR. Sex, age, best corrected visual acuity (BCVA), intraocular pressure (IOP) and cup-to-disc ratio (CDR) did not differ between the two groups. mean corpuscular volume (MSV), lactate dehydrogenase (LDH) and percentage of foetal haemoglobin (HbF) were reduced in the patients with PSR compared to NPSR. The best predictor of PSR was MSV, followed by HbF and LDH. The size of Foveal Avascular Zone (FAZ) on OCTA were similar in both groups. The authors postulate that these associations indicate that hypoxia, not haemolysis, is a possible driving force in sickle cell retinopathy (SCR) pathophysiology. This study proposes MSC and HbF as possible biomarkers to be used for screening for PSR. Further studies on red blood cell interaction with endothelial cells are advised. – Kurt Spiteri Cornish
Identifying clinical predictors of proliferative sickle cell retinopathy. Serras-Pereira R, Vieira L, Saunders CJ, et al. CURRENT EYE RESEARCH 2023;48(11):1063–7. Taylor & Francis Group
Freshly polished and ready for your visual pathway, here is a short and sweet dose of upcoming dates which demand a place in your calenders:
April, welcome. Your sunshine has been sincerely missed. Now that our rooms are tidy and we’ve dusted off the remaining remnants of winter, we look ahead with fresh faces ready for the coming months. And to mark the occasion, let’s bring in our trusted and faithful free book giveaway...
This month, we have something a little more focused and refined: Integrated Intraoperative Ocular Coherence Tomography for Pediatric Ocular Surgery (2021) edited by Ken K. Nischal MD,FAAP,FRCOphth . This wonderful title from Karger Publishers is volume 61 in their insightful Developments in Ophthalmology series, and presents i2OCT in pediatric ocular surgery alongside case scenarios in paediatric retinal disease, corneal lamellar keratoplasty and paediatric cataract surgery.
As always, this is a first-come, first-serve basis. Just reach out to me via LinkedIn or email: samuel@pinpoint-scotland.com
Until next time, eye friends,