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In this week’s issue

• cpRNFL predicts visual field loss early in glaucoma, while mGCIPL becomes more informative with advancing disease.
• Vision loss increases fall risk in older adults when home hazards are present.
• Elevated aqueous humor L-lactate in uveal melanoma may reflect tumor metabolism, offering a potential noninvasive biomarker for early lesion detection.
• Transient vision loss signals elevated short- and long-term cardiovascular risk, emphasizing the need for urgent evaluation and ongoing follow-up.

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Ophthalmology

Complementary roles of cpRNFL & mGCIPL thickness in glaucoma

Two retinal thickness measurements are better than one! Circumpapillary retinal nerve fiber layer (cpRNFL) and macular ganglion cell inner plexiform layer (mGCIPL) thicknesses are widely used to monitor glaucoma progression. Historically, there has been much debate over which of these parameters better predicts clinically meaningful changes in visual field (VF). New research conducted by a Baltimore-based team suggests that both metrics have value, albeit at different stages of the disease. The study demonstrated that cpRNFL thinning is strongly associated with VF decline in glaucoma suspects, but it shows no significant association in patients with advanced glaucoma. In contrast, the effect of mGCIPL thinning on VF appears smallest in glaucoma suspects and increases with increasing disease severity. Together, these findings highlight the importance of a multi-metric, OCT-based approach to monitoring glaucoma progression.

JAMA Ophthalmology

Home hazards and falls in older adults with visual impairment

Watch your step. Prior studies have linked falls in older adults to environmental risk factors, particularly home hazards, but less is known about how these hazards interact with visual impairment. Using cross-sectional data from the National Health and Aging Trends Study, investigators examined whether home hazards modified the association between visual deficits, measured by distance visual acuity (DVA) and contrast sensitivity (CS), and falls among U.S. Medicare beneficiaries aged ≥65 years. Three home hazards were assessed: absence of bathroom grab bars, tripping hazards, and broken flooring. Among 4,648 participants (mean DVA 0.10 logMAR [Snellen 20/25]; mean CS 1.72 logCS), 52% had at least one home hazard. Worsening DVA was strongly associated with increased fall risk, but only in the presence of home hazards. Each 0.1 logMAR decrease in visual acuity (approximately one line of acuity loss) was associated with a 14% increase in fall odds in homes without grab bars, a 29% increase in homes with tripping hazards, and a 47% increase in homes with broken flooring. No significant association was observed in hazard-free homes. These findings underscore the need for two-pronged fall prevention strategies that combine treatment of visual deficits with targeted home safety interventions.

American Journal of Ophthalmology (AJO)

L-lactate in aqueous humor: Biomarker for uveal melanoma?

Could cancer cells leave a metabolic fingerprint in the eye? Uveal melanoma (UM) is the most common primary intraocular malignancy among U.S. adults and carries a poor prognosis once metastatic. Distinguishing small benign uveal lesions from malignant ones remains a diagnostic gray zone, and although fine-needle aspiration biopsy can be informative, its utility is limited when lesions are very small. Because cancer cells preferentially rely on glycolysis for energy, researchers hypothesized that this metabolic shift might serve as a marker for tumor activity in UM. In this case-control study, aqueous humor samples from eyes with UM (n = 34) and controls (n = 13) undergoing cataract surgery, were analyzed for L-lactate concentration and correlated with clinical, histopathologic, and molecular tumor characteristics. Aqueous L-lactate levels were significantly higher in UM eyes than controls and correlated with increased mitotic activity. These findings suggest that elevated aqueous humor levels of L-lactate may reflect tumor metabolic activity and may provide a foundation for developing noninvasive biomarkers to enable earlier identification of suspicious uveal lesions.

British Journal of Ophthalmology

Is transient vision loss a warning sign of cardiovascular disease?

Sometimes a fleeting visual symptom signals a much more lasting risk. Transient vision loss (TVL) is often regarded as a brief, self-limiting ocular event; however, it may reflect underlying vascular pathology. Although its association with increased stroke risk is well recognized, less is known about the broader and longer-term cardiovascular risks following an initial TVL diagnosis. In this retrospective, propensity score-matched cohort study, 37,750 patients with a first diagnosis of TVL were compared with matched controls with dry eye syndrome for outcomes including major adverse cardiovascular events (MACE), stroke, myocardial infarction (MI), ventricular arrhythmias, venous thromboembolism (VTE), hospitalization, and all-cause mortality from 14 days to 10 years. At 14 days, patients with TVL had a 21-fold higher risk of stroke, nearly 10-fold higher risk of MACE, over 4-fold higher risk of arrhythmia, 5-fold higher risk of MI, and nearly 4-fold higher risk of hospitalization. Elevated risks of MACE, stroke, arrhythmia, and hospitalization persisted up to a decade, though attenuating over time, even among patients who remained event-free at 90 days or one year. These findings underscore transient vision loss as an important warning sign, with the greatest cardiovascular risk concentrated in the first 90 days and a sustained elevation compared to controls for years thereafter, highlighting the need for both urgent evaluation and long-term cardiovascular follow-up.

Retina

Socioeconomic factors and visual outcomes in neovascular AMD

What’s the price of sight? By 2050, the number of individuals with neovascular age-related macular degeneration (nAMD) in the United States is projected to more than double, from 2.07 million to 5.44 million. Anti-vascular endothelial growth factor (anti-VEGF) therapy remains the standard of care to slow disease progression, yet outcomes may vary by socioeconomic status. In this retrospective study using U.S. census data, investigators analyzed the impact of socioeconomic status (SES) on best-corrected visual acuity (BCVA) and anti-VEGF treatment patterns. Lower income was associated with a significantly worse baseline and final BCVA. Multivariable regression analysis demonstrated that worse baseline BCVA and older age independently predicted worse final BCVA, while higher income was associated with better final BCVA. Treatment patterns also differed by ethnicity: Hispanic or Latino individuals were less likely to receive aflibercept injections and more likely to receive bevacizumab compared to Non-Hispanic or Latino individuals. This study demonstrates both anti-VEGF selection and final nAMD BCVA results differ by income and ethnicity, highlighting potential areas of inequity in ophthalmic care.

Journal: BMJ Open Ophthalmology

Enhancing AI-based diabetic retinopathy diagnosis

Diabetic retinopathy (DR) is a leading cause of preventable vision loss, and timely screening is essential to reduce disease progression. Although deep learning (DL) algorithms have demonstrated strong performance in DR detection, their clinical deployment is often limited by variability in retinal images acquired from different fundus cameras, particularly portable devices used in community screening programs. In this study, researchers evaluated a style-adaptation deep learning framework designed to improve model robustness across heterogeneous imaging systems. Retinal images captured using both portable and standard fundus cameras were harmonized using a Style-Consistent Retinal Image Transformation Network prior to classification. The adapted model achieved approximately 79% diagnostic accuracy, with high agreement with expert graders (κ ≈ 0.89), while reducing false positives compared to non-adapted models. These results demonstrate that camera-independent AI systems can maintain reliable DR detection across diverse clinical environments. Such adaptability is critical for scaling AI-driven screening programs, particularly in low-resource settings, and may help bridge gaps in access to early ophthalmic care.

Comparison of AMD Treatments Trials (CATT)

An anti-VEGF a month keeps the ophthalmologist away, but which one? The CATT trials looked to assess the relative safety and efficacy of two treatments for subfoveal neovascular Age-Related Macular Degeneration (AMD). Most AMD-related blindness is attributable to choroidal neovascularization and therefore anti-VEGF therapy treatment was a crucial development in the fight to improve visual outcomes. In the CATT trial, patients with AMD (n=1185) were randomized to receive either intraocular injections of ranibizumab or bevacizumab (a cheaper, off-label alternative) at either a monthly or as needed regimen. Those patients in the monthly arm of the trial were equally divided again after 1 year to either remain monthly or switch to as needed.

Key Points

• Ranibizumab and bevacizumab had similar effects on visual acuity (mean increase in letters of visual acuity from baseline was 8.8 in the ranibizumab-monthly group, 7.8 in the bevacizumab-monthly group, 6.7 in the ranibizumab-as-needed group, and 5.0 in the bevacizumab-as-needed group)
• Switching to as-needed treatment after one year of monthly treatment yielded outcomes nearly equal to those obtained with as-needed treatment for the full two years, with the mean number of injections was 5.0 for ranibizumab-treated patients and 5.8 for bevacizumab-treated patients
• There were no differences between the two drugs in rates of death or arteriothrombotic events, which are sometimes associated with systemic anti-VEGF treatment for cancer

The CATT was the first multicenter and largest trial to compare bevacizumab to ranibizumab (the more expensive, yet standard of the time). This study was crucial to establish the differences and similarities of the two drugs, primarily the non-inferiority of bevacizumab on similar treatment frequencies.