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.

Rates of Reoperation and Retinal Detachment after Macular Hole Surgery.

PURPOSE: To evaluate rates of reoperation and retinal detachment (RD) after macular hole surgery. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Patients in the insurance claim-based MarketScan databases from 2007 through 2013 with a record of macular hole surgery. METHODS: Patients with macular hole surgery were identified. Cases of definite (the same eye was coded both times) and presumed (the eye laterality was not coded) macular hole reoperations within 2, 3, and 12 months were queried. In addition, cases of postoperative RD within 2, 3, and 12 months were captured. MAIN OUTCOME MEASURES: Rates of macular hole reoperation and postoperative RD, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling. RESULTS: Records of 23465 macular hole surgeries among 20 764 patients were analyzed. Among presumed reoperations, the rates of reoperation were 4.3% (4.1% after ILM peeling and 5.0% after no ILM peeling; P = 0.01) within 2 months of surgery, 5.5% (5.3% after ILM peeling and 6.2% after no ILM peeling; P = 0.03) within 3 months of surgery, and 9.5% (9.0% after ILM peeling and 11.0% after no ILM peeling; P = 0.01) within 12 months of surgery. The rates for definite reoperations were 1.3% (1.2% after ILM peeling and 1.8% after no ILM peeling; P = 0.04) at 2 months, 1.7% (1.6% after ILM peeling and 2.5% after no ILM peeling; P = 0.004) at 3 months, and 4.1% (3.3% after ILM peeling and 7.5% after no ILM peeling; P < 0.001) at 12 months. The cumulative rate of postoperative RD was 1.81±0.09% to 2.18±0.5% after 2 months, 2.27±0.10% to 3.18±0.67% after 3 months, and 3.92±0.16% to 5.70±1.1% after 12 months. Internal limiting membrane peeling was associated negatively with postoperative RD at 2 months (2.3% vs. 1.7%; P = 0.007), 3 months (2.8% vs. 2.1%; P = 0.004), and 12 months (4.7% vs. 3.3%; P < 0.001). CONCLUSIONS: In this sample, reoperations for macular hole were performed at low rates. Internal limiting membrane peeling was associated with lower rates of reoperation and RD.

Incidence of Acute Cystoid Macular Edema after Starting a Prostaglandin Analog Compared with Other Classes of Glaucoma Medications.

PURPOSE: There is a longstanding belief that prostaglandin analogs (PGAs) may predispose patients with glaucoma to develop acute cystoid macular edema (CME). However, there is little solid evidence supporting this notion. The purpose of this study is to compare CME incidence rates among patients initiating treatment with different glaucoma medication classes. DESIGN: Database study. PARTICIPANTS: A total of 39 948 patients who were newly prescribed glaucoma medications METHODS: Using data from 10 health systems contributing data to the Sight Outcomes Research Collaborative Ophthalmology Data Repository, we identified all adults with glaucoma who had been newly started on a topical glaucoma medication. Patients with pre-existing documentation of macular edema were excluded. We assessed the incidence of CME among patients with glaucoma who were newly started on PGAs, topical beta blockers (BBs), alpha agonists (AAs), and carbonic anhydrase inhibitors (CAIs). Using multivariable logistic regression, and adjusting for sociodemographic factors, we assessed the odds of developing CME among patients prescribed each of the 4 glaucoma medication classes. We also performed a subset regression analysis including lens status as a covariate. MAIN OUTCOME MEASURES: Incidence of CME within 3 months of initiating therapy with different topical glaucoma medications. RESULTS: Among the 39 948 patients who were newly treated with a topical glaucoma medication, 139 (0.35%) developed CME. The incidence of CME was 0.13%, 0.65%, 0.55%, and 1.76% for users of PGAs, BBs, AAs, and CAIs, respectively. After adjusting for sociodemographic factors, users of topical BBs, AAs, and CAIs had substantially higher odds of developing CME compared with PGA users (P < 0.001 for all comparisons). The subset analysis also showed higher odds ratio of the non-PGA medication classes in association with CME. CONCLUSIONS: Clinicians should reconsider the notion that PGAs carry a higher risk of CME versus other glaucoma medication classes. If additional studies support the findings of these analyses, clinicians may feel more comfortable prescribing PGAs to patients with glaucoma without fear they will predispose patients to CME. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Safety and Efficacy of Diode Laser Transscleral Cyclophotocoagulation in Eyes With Good Visual Acuity.

BACKGROUND/AIMS: The main aim of this study was to evaluate the safety and efficacy of diode laser transscleral cyclophotocoagulation (TSCPC) in eyes with good visual acuity. PATIENTS AND METHODS: A retrospective chart review identified patients who underwent TSCPC for uncontrolled intraocular pressure (IOP) from 2014 to 2016. Enrollment criteria included pretreatment best-corrected visual acuity (BCVA) of 20 of 40 or better, and a minimum of 6 months of postoperative follow-up. RESULTS: Thirty-three eyes of 33 patients(mean age, 72.1±16.0 y) were enrolled (mean follow-up 12.6±6.1 mo). The mean (SD) IOP was reduced 48.3% from 27.1 mm Hg (7.8) at baseline to 13.1 mm Hg (4.2) at last follow-up. Reduction of ≥1 glaucoma medications was achieved in 17 eyes (51.5%) at last follow-up. The cumulative probability of complete success (BCVA loss <2 Snelling lines, 20% reduction IOP, no reoperation for glaucoma, no IOP<5 mm Hg) was 78.8% and 50% at months 6 and 12, respectively. The cumulative probability of qualified success (BCVA≥2 lines with ≥20% reduction IOP, no reoperation for glaucoma, no IOP<5 mm Hg) was 90.1% and 81.3% at month 6 and 1 year, respectively. Significant vision loss, defined as BCVA≥2 lines, occurred in 33% of patients. The most common complications were postoperative iritic (56.3%) and cystoid macular edema (12.5%). CONCLUSIONS: TSCPC demonstrates a strong reduction in IOP and glaucoma medication use. However, with significant vision loss in 33% of patients, future prospective studies with a comparison group receiving traditional glaucoma surgery are needed to determine comparative safety and efficacy.

Tamponade in the surgical management of retinal detachment.

Despite treatment advances, rhegmatogenous retinal detachment (RD) can have poor visual outcomes even with prompt and appropriate therapy. Pars plana vitrectomy is a leading management modality for the treatment of RD. This procedure is generally accompanied by the use of internal tamponade. Various gases and silicone oils may yield beneficial outcomes. Heavy silicone oils have been approved in some European nations but are not available in the USA. Different tamponade agents have unique benefits and risks, and choice of the agent should be individualized according to the characteristics of the patient and RD, as well as perioperative and postoperative factors.

Rates of Reoperation and Abnormal Binocularity Following Strabismus Surgery in Children.

PURPOSE: To determine predictors of reoperation and abnormal binocularity outcomes (including amblyopia and diplopia) following pediatric strabismus surgery. DESIGN: Retrospective cross-sectional study. METHODS: setting: Review of a national insurance database. STUDY POPULATION: Children under age 18 years having strabismus procedures between 2007 and 2013. INTERVENTIONS: Adjustable- or fixed-suture strabismus surgery, or botulinum toxin injection. OUTCOME MEASURES: Reoperation or diagnosis of abnormal binocularity in the first postoperative year. RESULTS: Of 11 115 children having strabismus procedures, 851 (7.7%) underwent reoperation. The reoperation rate was 7.4% for fixed-suture surgeries, 9.6% for adjustable-suture surgeries (P = .18), and 44.9% for botulinum injections (P < .001). Age under 2 years was associated with higher reoperation and abnormal binocularity rates (P < .001). For horizontal strabismus, the postoperative abnormal binocularity rate was 12.8% for fixed-suture surgery and 26.5% for botulinum injection (P = .005). Reoperation rates tended to be higher with adjustable sutures (odds ratio [OR] 1.69, 95% confidence interval [CI] 0.94-3.03, P = .08) or botulinum toxin injection (OR 10.36, 95% CI 5.75-18.66, P < .001) and lower with 3- or 4-muscle surgery (P = .001). Esotropia, hyperopia, and botulinum injection were independently associated with higher rates of postoperative abnormal binocularity (P ≤ .005). For vertical surgeries, predictors of reoperation were adjustable-suture use (OR 2.51, P = .10) and superior oblique surgery (OR 2.36, P < .001). CONCLUSIONS: Adjustable sutures were not associated with a lower reoperation rate in children. Younger age, esotropia, hyperopia, and botulinum injection were associated with postoperative abnormal binocularity. Superior oblique surgery and botulinum injection were associated with higher rates of reoperation.

Mining Retrospective Data for Virtual Prospective Drug Repurposing: L-DOPA and Age-related Macular Degeneration.

BACKGROUND: Age-related macular degeneration (AMD) is a leading cause of visual loss among the elderly. A key cell type involved in AMD, the retinal pigment epithelium, expresses a G protein-coupled receptor that, in response to its ligand, L-DOPA, up-regulates pigment epithelia-derived factor, while down-regulating vascular endothelial growth factor. In this study we investigated the potential relationship between L-DOPA and AMD. METHODS: We used retrospective analysis to compare the incidence of AMD between patients taking vs not taking L-DOPA. We analyzed 2 separate cohorts of patients with extensive medical records from the Marshfield Clinic (approximately 17,000 and approximately 20,000) and the Truven MarketScan outpatient and databases (approximately 87 million) patients. We used International Classification of Diseases, 9th Revision codes to identify AMD diagnoses and L-DOPA prescriptions to determine the relative risk of developing AMD and age of onset with or without an L-DOPA prescription. RESULTS: In the retrospective analysis of patients without an L-DOPA prescription, AMD age of onset was 71.2, 71.3, and 71.3 in 3 independent retrospective cohorts. Age-related macular degeneration occurred significantly later in patients with an L-DOPA prescription, 79.4 in all cohorts. The odds ratio of developing AMD was also significantly negatively correlated by L-DOPA (odds ratio 0.78; confidence interval, 0.76-0.80; P <.001). Similar results were observed for neovascular AMD (P <.001). CONCLUSIONS: Exogenous L-DOPA was protective against AMD. L-DOPA is normally produced in pigmented tissues, such as the retinal pigment epithelium, as a byproduct of melanin synthesis by tyrosinase. GPR143 is the only known L-DOPA receptor; it is therefore plausible that GPR143 may be a fruitful target to combat this devastating disease.

New Therapeutic Approaches in Diabetic Retinopathy.

Diabetic retinopathy is a common microvascular complication of diabetes mellitus. It affects a substantial proportion of US adults over age 40. The condition is a leading cause of visual loss. Much attention has been given to expanding the role of current treatments along with investigating various novel therapies and drug delivery methods. In the treatment of diabetic macular edema (DME), intravitreal pharmacotherapies, especially anti-vascular endothelial growth factor (anti-VEGF) agents, have gained popularity. Currently, anti-VEGF agents are often used as first-line agents in center-involved DME, with recent data suggesting that among these agents, aflibercept leads to better visual outcomes in patients with worse baseline visual acuities. While photocoagulation remains the standard treatment for proliferative diabetic retinopathy (PDR), recent FDA approvals of ranibizumab and aflibercept in the management of diabetic retinopathy associated with DME may suggest a potential for pharmacologic treatments of PDR as well. Novel therapies, including small interfering RNAs, chemokines, kallikrein-kinin inhibitors, and various anti-angiogenic agents, are currently being evaluated for the management of diabetic retinopathy and DME. In addition to these strategies, novel drug delivery methods such as sustained-release implants and refillable reservoir implants are either under active evaluation or have recently gained FDA approval. This review provides an update on the novel developments in the treatment of diabetic retinopathy.

Strabismus Surgery Reoperation Rates With Adjustable and Conventional Sutures.

PURPOSE: To determine the association of strabismus surgery reoperation rates with adjustable or conventional sutures. DESIGN: Retrospective cross-sectional study. METHODS: setting: Review of a large national private insurance database. STUDY POPULATION: Adults aged 18-89 having strabismus surgery between 2007 and 2011. INTERVENTION: Adjustable vs conventional suture strabismus surgery. OUTCOME MEASURE: Reoperation rate in the first postoperative year. RESULTS: Overall, 526 of 6178 surgical patients had a reoperation (8.5%). Reoperations were performed after 8.1% of adjustable suture surgeries and after 8.6% of conventional suture surgeries (P = .57). Of the 4357 horizontal muscle surgeries, reoperations were performed after 5.8% of adjustable suture surgeries, and after 7.8% of conventional suture surgeries (P = .02). Of the 1072 vertical muscle surgeries, reoperations were performed after 15.2% of adjustable suture surgeries and after 10.4% of conventional suture surgeries (P = .05). Younger age (18-39 years) was associated with a lower reoperation rate (P ≤ .02). The significant multivariable predictors of reoperation for horizontal surgery were adjustable sutures (odds ratio [OR] 0.69, 95% confidence interval 0.52-0.91), monocular deviation (OR 0.64), complex surgery (OR 1.63), and unilateral surgery on 2 horizontal muscles (OR 0.70, all P ≤ .01). Adjustable sutures were not significantly associated with reoperation rates after vertical muscle surgery (multivariable OR 1.45, P = .07). CONCLUSIONS: Adjustable sutures were associated with significantly fewer reoperations for horizontal muscle surgery. Adjustable sutures tended to be associated with more reoperations for vertical muscle surgery, but this observation was not statistically significant in the primary analysis after controlling for age.

Incidence of postoperative suprachoroidal hemorrhage after glaucoma filtration surgeries in the United States.

PURPOSE: To report the 3-month incidence rates of postoperative suprachoroidal hemorrhage after glaucoma filtration surgeries and to examine the subsequent surgical treatments in these eyes. METHODS: This is a retrospective study using the nationally pooled, insurance claim-based MarketScan databases from the years 2007-2011. Patients with records of trabeculectomy and/or tube shunt procedures were identified, and all cases of "definite" (ie, properly coded) and "suspected" (possibly miscoded) postoperative suprachoroidal hemorrhage occurring within 3 months of their glaucoma filtration procedures were captured along with the surgical interventions used for this condition. Kaplan-Meier survival analysis was used to evaluate the 3-month incidence rates of suprachoroidal hemorrhage, and regression analysis was applied to calculate the odds ratios, confidence intervals, and P-values. RESULTS: There were 17,843 trabeculectomies and 9,597 tube shunt surgeries identified. Among these, there were 107 cases (247 including "suspected" cases) of postoperative suprachoroidal hemorrhage within 3 months of trabeculectomy and 113 cases (255 including "suspected" cases) within 3 months of tube shunt procedures. The 3-month cumulative incidence rate of postoperative suprachoroidal hemorrhage ranged from 0.6%±0.06% to 1.4%±0.09% after trabeculectomy and 1.2%±0.11% to 2.7%±0.16% after tube shunt surgery. Postoperative suprachoroidal hemorrhage was almost twice as likely to occur after tube shunt surgeries than after trabeculectomies for both "definite" and "definite" plus "suspected" cases (odds ratio, 1.98; 95% confidence interval, 1.51-2.58; P<0.001; and odds ratio, 1.95; 95% confidence interval, 1.63-2.32; P<0.001, respectively). Among the 502 "definite" and "suspected" cases of postoperative suprachoroidal hemorrhage, 32.9% (165 cases) had a treatment record of choroidal tap and 8.8% (44 cases) had a treatment record of pars plana vitrectomy. CONCLUSION: In this sample, the 3-month cumulative incidence rate of postoperative suprachoroidal hemorrhage was 0.6%-1.4% after trabeculectomy and 1.2%-2.7% after tube shunt procedures, and the majority of the cases appeared to be managed without further surgery. Postoperative suprachoroidal hemorrhage was almost twice as likely to occur after tube shunt surgeries as after trabeculectomies.