Association of Primary Open-Angle Glaucoma with Diabetic Retinopathy among Patients with Type 1 and Type 2 Diabetes: A Large Global Database Study.

PURPOSE: To assess the correlation between primary open-angle glaucoma (POAG) and the risk of developing diabetic retinopathy (DR) in patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). DESIGN: A retrospective cohort study leveraging the global patient database of TriNetX Research Network. PARTICIPANTS: The study included 44 359 patients with diabetes mellitus (DM) with POAG and 4 393 300 patients with DM without any glaucoma ≥ 18 years of age. Propensity score matching harmonized the cohorts to 39 680 patients each, covering diagnoses from January 1, 2005, to January 1, 2023. METHODS: We analyzed data using specific International Classification of Diseases, 10th Revision (ICD-10) codes for DM and glaucoma. We matched the cohorts using propensity score matching, adjusting for age, sex, race/ethnicity, blood markers, relevant medical history, and ophthalmic service use. MAIN OUTCOME MEASURES: The primary outcome was the first-time occurrence of DR, including nonproliferative DR (NPDR) and proliferative DR (PDR), in patients with DM with and without glaucoma at 1-, 5-, and 10-year intervals from their individual index dates. RESULTS: At 10 years, patients with T1DM with POAG exhibited a heightened risk for any DR (adjusted risk ratios [RRs], 4.12; 95% confidence interval [CI], 3.05-5.57, P < 0.0001) and PDR (RR, 7.02; 95% CI, 3.62-13.61, P < 0.0001). Patients with T2DM and POAG also faced an increased 10-year risk for any DR (RR, 2.47; 95% CI, 2.28-2.68, P < 0.0001) and PDR (RR, 3.82; 95% CI, 3.09-4.70, P < 0.0001). The combined association of POAG on DR risk in those with T1DM and T2DM at 10 years was found to be significantly higher among patients with POAG (5.45%) compared with those without glaucoma (2.12%) (adjusted hazard ratio [aHR], 2.33; 95% CI, 2.14-2.53). The cumulative incidence of DR was significantly higher in the POAG group compared with nonglaucoma counterparts after a decade (log-rank P < 0.001). CONCLUSIONS: Our findings underscore a substantial association between POAG and DR development in both T1DM and T2DM patients, emphasizing the need for vigilant screening and comprehensive management in glaucomatous patients with DM to mitigate the risk of DR. Future research should delve into elucidating the causal mechanisms driving these observed associations. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Lifestyle modifications and environmental risk factors for glaucoma.

PURPOSE OF REVIEW: To summarize recent evidence about the association between different lifestyle modifications and environmental risk factors and glaucoma. RECENT FINDINGS: Incorporating moderate exercise into the routine of glaucoma patients may help slow the progression of the condition. However, caution should be taken when using swim goggles, and it may be advisable to avoid certain yoga positions and heavy weight-lifting exercises, as they have been linked to intraocular pressure (IOP) spikes and potential risks for glaucoma patients. Various relaxation techniques may lower IOP. The evidence remains inconclusive about the association between vitamins intake and glaucoma. Dietary nitric oxide has been associated with a lower risk of glaucoma. Higher smoking intensity has been linked to faster visual field decline and retinal nerve fiber layer thinning. Additionally, there is currently insufficient evidence to support the use of marijuana in managing glaucoma, with side effects outweighing the proposed benefits. A significant association has been found between air pollutants and ganglion cell layer thinning, as well as a greater burden of glaucoma. SUMMARY: Lifestyle and environmental factors are increasingly recognized as significant contributors to glaucoma development and progression. These modifications should be integrated into a comprehensive treatment approach alongside medications or surgical interventions.

Pseudophakic cystoid macular edema.

PURPOSE OF REVIEW: Pseudophakic cystoid macular edema (PCME) is the most common postoperative complication of cataract surgery, resulting in visual decline. In this review, we discuss its pathophysiology, epidemiology, clinical presentation, and the current available evidence on therapeutic management. RECENT FINDINGS: Patients with diabetes mellitus have twice the risk of developing PCME as compared to nondiabetic individuals. Recent large database studies have revealed an increased risk among young, male, and black patients. A previous history of PCME is perhaps the strongest risk factor for fellow eye involvement. SUMMARY: PCME generally occurs around 6 weeks postoperatively and is likely a consequence of postoperative inflammation with disruption of the blood-queous and blood-retina barriers. Optical coherence tomography of the macula servers as a key diagnostic tool. There is a lack of large controlled clinical trials to guide treatment approaches. We recommend a stepwise approach for PCME that includes observation if not visually significant versus treatment with topical nonsteroidal anti-inflammatory drugs and steroids if symptomatic. Refractory cases can be treated with a periocular steroid injection, followed by intravitreal steroids if still nonresponsive.

Quality, Reliability, and Readability of Online Information on Idiopathic Intracranial Hypertension.

BACKGROUND: To evaluate the quality & reliability, technical quality, and readability of patient-targeted online information on idiopathic intracranial hypertension. METHODS: In this cross-sectional study, we searched Google and Bing search engines for the terms "idiopathic intracranial hypertension" and "pseudotumor cerebri." We evaluated the first 50 search outcomes for each search term. Peer-reviewed articles, targeted advertisements, book chapters, videos, personal blogs, websites intended for healthcare professionals, and non-English websites were excluded. Websites were classified as institutional or private. Two independent reviewers assessed each website for 1) quality and reliability using DISCERN, Health on the Net Code of Conduct (HONcode), and JAMA criteria and 2) technical quality based on 11 criteria. Readability was evaluated using 6 measures (Flesch-Kincaid Reading Ease score and grade level, Gunning Fog, Simple Measure of Gobbledygook (Smog) index, Coleman-Liau index, and automated readability index). RESULTS: Sixty-three websites (37 institutional) were included. The mean scores for the DISCERN, HONcode, and JAMA criteria were 3.6 ± 1 (1-4.8; 1: worse, 5: best), 10.3 ± 2.8 (2-16; 0: worse, 16: best), and 2 ± 1.3 (0-4; 0: worse, 4: best), respectively. The mean technical quality score was 0.8 ± 0.1 (0.5-1). The mean Flesch-Kincaid grade level score was 8.9 ± 1.8 (3.3-13.3). For Flesch-Kincaid grade level, 47 (74.6%) websites scored a grade level of 10 or less. For Gunning Fog Score, 35 websites (55.6%) scored from 7.3 to 10.8. For the Smog Index, 46 (73%) websites scored 5.7-8. The mean Coleman Liau Index was 16 ± 2.1 (9.6-22.2). For the automated readability index, 30 (50.7%) websites scored less than the eighth grade. No statistically significant difference was present between institutional and private websites except for JAMA, which scored higher in private websites (2.4 vs 1.7, P = 0.03). CONCLUSIONS: Our findings suggest that online information on idiopathic intracranial hypertension/pseudotumor cerebri for patients generally demonstrates moderate to good quality and reliability. Although most websites maintain credible technical quality, the readability exceeds recommended levels for the average American reader. This may impede understanding, emphasizing the need for future improvements.

Isolated eyelid neonatal Langerhans cell histiocytosis.

Langerhans cell histiocytosis (LCH) is a condition characterized by clonal proliferation of the phagocytic cells derived from the bone marrow. In this article, we present an exceedingly rare case of congenital/neonatal LCH in a 3-week-old girl who initially presented with an isolated swelling of the eyelid, initially misdiagnosed as a chalazion. Subsequently, a biopsy was performed, and histopathological evaluation confirmed the diagnosis of LCH. A staging work-up revealed no evidence of multisystem involvement, and thus, local steroid injection was performed as the initial treatment for the residual lesion. Cases of localized LCH that manifest as eyelid masses are rare, and most reported cases involve children over the age of one year. To the best of our knowledge, this case represents the first reported instance of neonatal LCH presenting as an eyelid mass. Although neonatal LCH is rare, ophthalmologists must be aware of this presentation and include it in the differential diagnosis for eyelid lesions in infants during the first month of life.

Cataract surgery in myopic eyes.

PURPOSE OF REVIEW: We discuss the preoperative, intraoperative, and postoperative considerations for cataract surgery in eyes with high myopia. We also reviewed the recent literature on refractive outcomes and complications of cataract surgery in myopic eyes. RECENT FINDINGS: Several novel intraocular lens (IOL) power calculation formulas have recently been developed to optimize refractive outcomes. Haigis formula is the most accurate among the third-generation IOL formulas. Novel formulas such as Barrett Universal II, Kane, and modified Wang-Koch adjustment for Holladay I formula provide a better refractive prediction compared with old formulas. Intraoperatively, the chopping technique is preferred to minimize pressure on weak zonules and reduce the incidence of posterior capsule rupture. Anterior capsular polishing is recommended to reduce the risk of postoperative capsular contraction syndrome (CCS). Postoperatively, complications such as refractive surprises, intraocular pressure spikes, and CCS remain higher in myopic eyes. Only 63% of myopic patients with axial length more than 26 mm achieve a visual acuity at least 20/40 after cataract surgery, mainly because of coexisting ocular comorbidities. SUMMARY: There are multiple preoperative, intraoperative, and postoperative considerations when performing cataract surgery in myopic eyes. Further research is needed to optimize the refractive outcomes in these eyes and determine the best IOL formula. Surgeons should be adept and knowledgeable with different techniques to manage intraoperative complications.

Cataract surgery in adult eyes with short axial length.

PURPOSE OF REVIEW: Cataract surgery in eyes of patients with short axial length (AL) can be technically challenging and is associated with a high risk of intra- and postoperative complications. Several technical and surgical strategies have been proposed to optimize the visual outcome and decrease the rate of surgical complications and it is important to understand their applications in these cases. RECENT FINDINGS: Traditional intraocular lens (IOL) measurement formulas in eyes with short AL have reduced reliability. Novel formulas such as the Kane formula provide a better refractive prediction. Surgery can be difficult in short eyes due to the crowdedness of the anterior chamber (AC) and the associated scleral abnormalities increasing the risk of uveal effusion. Surgical techniques such as prophylactic scleral incisions, limited pars plana anterior vitrectomy, and modified hydrodissection, have been shown to facilitate surgery in extremely short eyes and decrease the rate of operative complications. Although cataract surgery improves vision in these cases, short AL and shallow AC have been associated with worse visual outcomes. SUMMARY: Newer 4 th generation IOL formulas have improved the refractive outcomes of cataract surgery in eyes with short AL. There are multiple evolving surgical strategies for optimizing surgery in these eyes. However, studies on the surgical and visual outcomes of cataract surgery in eyes with short AL are limited by their design and sample size. With further research and continued clinical experiences, we hope to develop evidence-based algorithms for the management of these complex cases.

Impact of axial length on visual outcomes and complications in phacoemulsification surgery: a multicenter database study.

PURPOSE: To analyze the impact of axial length (AL) on the visual outcome and rate of perioperative complications in phacoemulsification surgery. DESIGN: Retrospective clinical database study. METHODS: Cataract surgery data of 217,556 eyes was extracted from the electronic medical records of 8 ophthalmic centers in the United Kingdom from July 2003 to March 2015. A total of 88,774 eyes without ocular co-pathologies were grouped eyes according to AL (mm): short AL (< 22), average AL (22-26; reference group), and long AL (> 26). MAIN OUTCOMES AND MEASURES: We analyzed visual acuity (VA) outcomes at 4 weeks, 4-12 weeks, and 12-24 weeks postoperatively, as well as the incidence of posterior capsular rupture (PCR), torn iris (TI), cystoid macular edema (CME), and retinal detachment (RD). RESULTS: Mean pre-operative VA (logMAR) was the worst in eyes with long AL compared to average and short AL eyes (VA 0.59 vs. 0.58 and 0.56; p < 0.001). However, post-operative VA at 4-12 weeks was slightly better in the long AL group (0.14 in short and average AL; 0.12 in long AL, p < 0.001). We observed an increased odds of TI in the short AL group (OR 2.09, 95% CI 1.60-2.75). There was increased risk of RD in long AL eyes (p < 0.001). However, PCR and CME rates were not different. CONCLUSION: In the absence of any coexisting ocular pathology, AL alone did not have an impact on VA improvement or the risk of encountering PCR or CME. The risk of TI was greater in the short AL group, and the risk of RD was higher in the long AL group.

Hybrid 23/25-Gauge Direct Perfluorocarbon Liquid-Silicone Oil Exchange.

PURPOSE: To describe a novel technique for direct perfluorocarbon liquid (PFCL)-silicone oil exchange that aims to reduce the inherent risk of intraoperative intraocular pressure spike. METHODS: We use the conventional setup for passive PFCL-silicone exchange, but intentionally create a mismatch between the passive PFCL aspiration and the active silicone injection that favors the PFCL extrusion. This is achieved by converting one port to a large gauge one-23 or 20-gauge. RESULTS: We did not note the occurrence of high intraocular pressure spikes with this technique as noted by disk pallor or attenuated vessels. CONCLUSION: A hybrid 23/25-gauge technique for direct PFCL-silicone oil exchange is safe and reduces the risk of intraoperative intraocular pressure spike.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma.

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

Role of Matrix Metalloproteinase 9 in Ocular Surface Disorders.

OBJECTIVES: (1) To explore the role and significance of Matrix Metalloproteinase 9 (MMP-9), a proteolytic enzyme, in various ocular surface diseases of inflammatory, infectious, and traumatic etiology (2), to further elucidate the molecular mechanisms responsible for its overexpression in ocular surface disease states, and (3) to discuss possible targets of therapeutic intervention. METHODS: A literature review was conducted of primary sources from 1995 onward using search results populated from the US National Library of Medicine search database. RESULTS: MMP-9 overexpression has been found in in vitro and in vivo models of dry eye disease (DED), corneal ulceration, microbial keratitis, corneal neovascularization, ultraviolet light-induced radiation, and a host of additional surface pathologies. MMP-9 is involved in an intricate signal transduction cascade that includes induction by many proinflammatory molecules including interleukin-1 (IL-1), tumor necrosis factor alpha (TNF-a), nuclear factor kappa light chain enhancer of activated B cells (NF-kB), platelet-activating factor, activator protein 1 (AP-1), and transforming growth factor beta (TGF-B). MMP-9 expression is blunted by a diverse array of molecular factors, such as tissue inhibitors of metalloproteinases, cyclosporine A (CyA), PES_103, epigalloccatechin-3-gallate (EGCG), N-acetylcysteine (NaC), ascorbate, tetracyclines, and corticosteroids. Inhibition of MMP-9 frequently led to improvement of ocular surface disease. CONCLUSIONS: Novel insights into the mechanistic action of MMP-9 provide potential for new therapeutic modulations of ocular surface diseases mediated by its overexpression.