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| Vol. 26, #13 • Monday, April 1, 2024 |
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Off the Cuff: Primary Care Cases & Practice Motivation
Eight years ago I had a 45-year-old Middle Eastern man present with blurred vision in his left eye and a complaint of decreased peripheral vision developing over the last year. The right eye's visual acuity was 20/20, but the left eye was 20/70 and pinholed to only 20/50. He had a history of a retinal tear repair in his left eye, but that was more of a red herring and of no consequence. More concerning was the fact that the screening confrontation fields my technician performed, that rarely have a result other than “full to finger count,” were positive for temporal constriction on the right eye and nasal constriction on the left. His cup-to-disc ratios were large (.65 OU), but symmetric and intraocular pressures were OD 17 and OS 18. We ran a visual field. The results were profound and made me concerned for a stroke.
Even though the right homonymous hemianopsia made me question if this 45-year-old man had had a stroke, the defect did not respect the midline on his left eye. I referred him directly to neurology with these visual field results. The subsequent MRI report confirmed a massive pituitary macroadenoma measuring 4.8cm x 2.8cm x 2.9cm distorting the optic chiasm. Five weeks after his visit with me, he had surgery to remove as much of the tumor as they could. Initially, I began running monthly visual fields to see how much vision he would get back.
The visual field improved significantly over the next few years and even after a second debulking surgery performed in December 2019, the OS best-corrected visual acuity never improved beyond 20/50. All these years later, I still see him, his wife and kids and also his very appreciative sister and her family. On those tough days in the clinic, it’s cases like this that keep me motivated and remind me of the profound impact we can have not only on our patients’ visual well-being but their overall health as well. It is amazing to know that something as simple as a case of blurred vision can lead to a life-changing exam.
Want to share your perspective?
Write to Dr. Shannon L. Steinhäuser, OD, MS, FAAO at ssteinhauser@gmail.com.
The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.
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Corneal Collagen Crosslinking for Ectasia After Refractive Surgery: A Systematic Review and Meta-Analysis
Researchers wrote that corneal ectasia leads to progressive irregular corneal curvature and reduced visual acuity. To assess the safety and effectiveness of corneal collagen cross-linking (CXL) for managing corneal ectasia resulting from refractive laser surgery (RSL), they conducted a systematic review and meta-analysis according to PRISMA guidelines. They searched PubMed, EMBASE, Cochrane, and Web of Science databases for studies on CXL in patients with ectasia after RLS. The outcomes of interest included visual acuity, refractive outcomes, topographic parameters (Kmax, index surface variance (ISV), index of Vertical Asymmetry (IVA), keratoconus index (KI), central keratoconus index (CKI), index of height asymmetry (IHA), index of height decentration (IHD) and Rmin [minimum sagittal curvature]), central corneal thickness, endothelial cell count, and possible adverse events.
Fifteen studies encompassing 421 patients (512 eyes) were included. The mean age was 32.03 ± 4.4 years. The pooled results showed a stable uncorrected visual acuity post-CXL, with a significant improvement in corrected distance visual acuity. The spherical equivalent decreased significantly. The topographic parameter Kmax decreased significantly; however, the other parameters, ISV, IVA, KI, CKI, IHA, IHD, and Rmin, did not change significantly. Central corneal thickness decreased significantly, and the endothelial cell count remained stable. The complications were rare.
Researchers wrote that CXL was a safe and effective technique for managing corneal ectasia after RLS.
SOURCE: Dillan Cunha Amaral, Adriano Henrique Gomes Menezes, Luan Cavalcante Vilaça Lima, et al. Corneal Collagen Crosslinking for Ectasia After Refractive Surgery: A Systematic Review and Meta-Analysis. Clin Ophthalmol. 2024 Mar 19:18:865-879.
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The Relationship Between Artificial Intelligence-Assisted OCT Angiography-Derived Foveal Avascular Zone Parameters and Visual-Field Defect Progression in Eyes with Open-Angle Glaucoma
This retrospective longitudinal study investigated clinical factors associated with foveal avascular zone (FAZ) parameters obtained using OCT angiography (OCTA) with assistance from a previously developed artificial intelligence (AI) platform in eyes with open-angle glaucoma (OAG). This study followed 885 eyes of 558 patients with OAG for ≥ 2 years; all eyes underwent ≥ 5 Humphrey visual-field (VF) tests and had 3.0 × 3.0 mm macular OCTA scans available. Average total deviation (TD) in the superior, superocentral, inferocentral, and inferior sectors of the Humphrey 24-2 program was calculated. Investigators collected 3.0 × 3.0 mm macular OCTA images from each patient and used a previously developed AI platform with these images to obtain FAZ parameters, including FAZ area, FAZ circularity index (CI), and FAZ perimeter. Multivariable linear mixed-effects models were used to analyze the relationship between FAZ parameters, TD or TD slope in each quadrant, and systemic factors, adjusting for potential confounding factors, including axial length. Ophthalmic and systemic variables, FAZ parameters, and TD or TD slope in each quadrant.
The multivariable model showed that FAZ parameters were correlated with both TD and TD slope in the inferocentral quadrant (β=-0.244 - 0.168, p<0.001). Both upper-half and lower-half FAZ parameters were better associated with TD-inferocentral and TD-inferocentral slope than TD-superocentral or TD-superocentral slope in terms of β size and statistical significance, indicating that there was no evident vertical anatomical correspondence between TD in the central quadrant and FAZ parameters. Foveal avascular zone area enlargement was associated with female gender. Loss of FAZ circularity was associated with both aging and comorbid sleep apnea syndrome (SAS). Foveal avascular zone perimeter elongation was associated with aging and female gender.
Investigators concluded that artificial intelligence-assisted OCTA-measured FAZ enlargement and irregular shape might be good markers of ocular hypoperfusion and associated inferocentral VF defect progression in eyes with OAG.
SOURCE: Takahiro Ninomiya, Naoki Kiyota, Parmanand Sharma, et al. The Relationship Between Artificial Intelligence-Assisted OCT Angiography-Derived Foveal Avascular Zone Parameters and Visual-Field Defect Progression in Eyes with Open-Angle Glaucoma. Ophthalmol Sci. 2023 Aug 20;4(2):100387.
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Choriocapillaris Flow Features in Children With Myopic AnisometropiaMyopia
In this observational and prospective study, 46 children with myopic anisometropia were enrolled to examine differences between the eyes in choriocapillaris perfusion and choroidal thickness in children with myopic anisometropia. Choriocapillaris perfusion parameters, including the percentage of flow voids, the total number of flow voids and the average flow void area were obtained by optical coherence tomography angiography (OCTA). The OCTA image was divided into a 1 mm-diameter central circle (C1) and a 2.5 mm-diameter annulus (without the inner central 1 mm circle, C1-2.5). Both C1 and C1-2.5 are centered on the foveola. The C1-2.5 was divided into nasal (N1-2.5), temporal (T1-2.5), inferior (I1-2.5) and superior (S1-2.5) areas. Differences in these parameters in different regions between eyes were analyzed.
Researchers found no significant differences in the percentage of flow voids and the average flow void area between the fellow eyes. The total number of signal voids was significantly higher in the less myopic eyes in C1-2.5, S1-2.5, and N1-2.5. Changes in spherical equivalent refraction and axial length were both correlated with the changes in the total number of flow voids in N1-2.5.
The choroid in the macular region becomes thinner and the total number of flow voids in the nasal macular region decreased with the amplitude of myopia. This suggests that a decrease in total number of flow voids may indicate an early change in myopia.
SOURCE: Zhihao Jiang, Wu Bo, Zhengfei Yang, et al. Choriocapillaris flow features in children with myopic anisometropia. Br J Ophthalmol. 2024 Mar 25:bjo-2022-323020. Online ahead of print.
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Industry News
Announcements
• Registration is open for the Neuro-Optometric Rehabilitation Association, International (NORA) 34th annual conference, September 19-22, in Kissimmee, FL. Learn more.
• Cliara was granted its fifth US patent, for a novel device that accurately measures the force required to remove gas-permeable contact lenses from the eye—an innovation expected to contribute to the safety and comfort of contact lens wearers. The company is collaborating with BostonSight and LV Prasad Eye Institute in a clinical study to evaluate the effectiveness and applications of the device.
• A peer-review paper published in Drugs noted that Miebo®, perfluorohexyloctane ophthalmic solution, “is a valuable emerging option for the management of dry eye disease. Read more.
• LENZ Therapeutics, a late clinical-stage biopharmaceutical company focused on developing the first aceclidine-based eye drop to improve near vision in people with presbyopia, completed a merger with Graphite Bio. The new combined company operates under the name LENZ Therapeutics and began trading on Nasdaq under the ticker symbol “LENZ” on March 22. Read more.
• Ahead of the total solar eclipse on April 8, MyEyeDr is educating consumers about the importance of eye health and the need for proper eye protection while experiencing this once-in-a-lifetime event. Read more.
• Prevent Blindness declared April as Women’s Eye Health and Safety Month. Read more.
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Journal Reviews Editor:
Shannon L. Steinhäuser, OD, MS, FAAO
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Optometric Physician™ (OP) newsletter is owned and published by Dr. Shannon L. Steinhäuser. It is distributed by the Review Group, a Division of Jobson Medical Information LLC (JMI), 19 Campus Boulevard, Newtown Square, PA 19073.
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