In this week’s issue

• Major complications after strabismus surgery are rare but often vision-threatening, with higher risk in older patients and complex procedures.
• Protective eyewear remains underused among professional and amateur pickleball players despite rising eye injury risk.
• Modern diabetes therapies, SGLT2 inhibitors and GLP-1 receptor agonists, may help reduce cataract risk.
• Estrogen signaling may help maintain intraocular pressure homeostasis via the trabecular meshwork.

Spotify Link:

https://open.spotify.com/episode/5eO5pWnueB3tcHu20MbHrp?si=BO6LLb4vQ0WoepnHOOvxdQ

Ophthalmology

Major complications following strabismus surgery

What factors are associated with complications following strabismus surgery? Strabismus surgery is widely accepted to be relatively safe. Although reoperation rates range from 7% to 23% during the first decade, repeat surgeries are rarely due to intraoperative or perioperative errors. Because major complications occur so infrequently, incidence rates are obtained through inconsistent measures such as self-reporting, physician and patient questionnaires, and observation. Furthermore, data collected from these patient populations includes only a few thousand patients, making it difficult to determine frequency in large-scale populations. In this retrospective analysis of 134,635 eyes from the Intelligent Research in Sight Registry (IRIS) that underwent strabismus surgery, researchers sought to identify factors associated with complications in the first 60 days after surgery. One or more of the following complications occurred in 0.115% of patients: bacterial keratitis, orbital infection, endophthalmitis, and surgery for a lost or slipped muscle. Moreover, increasing age was associated with all complications except orbital infection. Female sex and age >65 were independent risk factors for endophthalmitis. Approximately half of all infections occurred within the first 5 days after surgery. With these data, physicians can obtain a more comprehensive informed consent for strabismus surgery. The authors also proposed postoperative assessment within 5 days of surgery to identify complications as early as possible. 

JAMA Ophthalmology 

Patterns and barriers to protective eyewear use in pickleball

That’s going to leave a mark. Pickleball’s rapid rise in popularity has been accompanied by a surge in eye injuries, ranging from corneal abrasions to traumatic iris hyphemas and retinal detachments. Despite this growing risk, little is known about how often players actually use protective eyewear. This study evaluated eyewear use and attitudes among professional and amateur pickleball players. Researchers analyzed tournament footage of 175 professional players and also surveyed 148 amateur players regarding eyewear use, motivations, and barriers to wearing eye protection. Only 20% of professionals and 45.27% of amateurs reported using eye protection, with 61% of amateurs relying on their regular prescription glasses rather than true protective eyewear. Additionally, among the amateur group, more advanced players reported using protective eyewear compared to beginners. Common motivators for wearing eye protection included the need for refraction, awareness of injury risk, and personally knowing someone with a pickleball associated eye injury. Barriers to wearing eye protection included discomfort from fogging or sweat, lack of perceived risk of eye injury during a game, and underestimation of severity of eye injuries. Improving awareness, accessibility, and comfort of sport-specific eyewear may be key to reducing preventable, vision-threatening injuries as pickleball continues to grow.

American Journal of Ophthalmology (AJO)

SGLT2 inhibitors and GLP-1 RAs associated with lower risk of cataracts

A clearer lens ahead. Cataract is a leading cause of vision loss globally, with age-related cataract highly prevalent in older adults and significantly exacerbated by type 2 diabetes mellitus. Newer medications such as SGLT2 inhibitors and GLP-1 receptor agonists (GLP-1 RA) have shown antioxidant and anti-inflammatory effects with potential relation to cataract development. This retrospective cohort study used data from the TriNetX database with 3-year follow up to compare the incidence of cataract diagnosis or surgery in propensity score-matched adults with type 2 diabetes receiving adjunctive SGLT2 inhibitors or GLP-1 receptor agonists vs. metformin alone, as well as SGLT2i vs. GLP-1 RA. Adjunctive SGLT2i and GLP-1 RA use were associated with a reduced risk of cataract formation compared to metformin (SGLT2i HR 0.82; GLP-1 RA HR 0.93), with SGLT2i demonstrating a greater protective effect than GLP-1 receptor agonists. This association was reduced in older, obese, and diabetic retinopathy subgroups. These findings support the potential ocular benefits of SGLT2i and GLP-1 RA in reducing the risk of cataracts in addition to their established metabolic effects.

Investigative Ophthalmology & Visual Science (IOVS)   

Can estrogen help keep eye pressure in balance?

Estrogen might play a protective role in maintaining intraocular pressure (IOP). Elevated IOP is the primary modifiable risk factor for glaucoma, often caused by dysfunction of aqueous humor outflow through the trabecular meshwork. Previous studies have suggested that low estrogen levels such as during menopause are associated with higher IOP and increased glaucoma risk, but the underlying mechanisms remain unclear. Understanding how estrogen affects trabecular meshwork biology could reveal new therapeutic targets for glaucoma prevention and treatment. Researchers studied mice lacking the estrogen receptor ESR1 and analyzed primary human trabecular meshwork cells exposed to transforming growth factor beta 2 (TGFβ2), a molecule known to induce glaucomatous changes. Female mice without ESR1 developed higher IOP compared to controls, particularly with aging. In cultured human trabecular meshwork cells, estrogen treatment reduced the harmful gene expression changes triggered by TGFβ2, including genes involved in extracellular matrix remodeling and fibrosis. These protective effects were especially evident under mechanical stretch conditions that mimic physiological pressure changes in the eye. Estrogen signaling appears to support IOP homeostasis by counteracting fibrotic and pressure-related stress in the trabecular meshwork. These findings suggest that estrogen pathways may represent a promising therapeutic target for glaucoma risk reduction, particularly in individuals with reduced estrogen levels.

Cornea

X-linked endothelial corneal dystrophy mimics other dystrophies

When a rare corneal dystrophy starts borrowing features from its neighbors. X-linked endothelial corneal dystrophy (XECD) is exceedingly rare, with this report examining patients from the only pedigree described to date. For cornea specialists, this makes careful phenotyping especially important because XECD can resemble other endothelial dystrophies and may complicate both diagnosis and surgical planning. In this study, the authors used slit-lamp examination, Scheimpflug tomography, anterior segment OCT, in vivo confocal microscopy, and specular microscopy to characterize 4 eyes from a 58-year-old woman and her 22-year-old son with genetically confirmed XECD. Female disease was limited largely to posterior corneal changes and guttae-like findings, whereas the male patient had thicker, more diffusely opaque corneas with stromal fibrosis, Descemet membrane hyperreflectivity, and moon crater-like lesions that overlapped phenotypically with FECD, PPCD, and CHED. The female patient showed moon crater-like posterior corneal lesions without stromal involvement, while the male patient had congenital diffuse stromal haze, greater corneal thickening and more severe confocal abnormalities. These multimodal findings suggest XECD may not be a cleanly distinct entity, but rather a phenotype that overlaps with other endothelial dystrophies. That distinction matters clinically since endothelial keratoplasty may be reasonable in milder female cases, while penetrating keratoplasty may be more appropriate in more advanced male disease. 

Treatment of AMD with Phototherapy (TAP) - 1999

In a world before anti-VEGF, what could we do for wet AMD? Prior to the use of anti-VEGF injections, treatment options for wet AMD were very limited. The TAP study sought to evaluate the efficacy of Verteporfin Photodynamic Therapy (PDT) in reducing vision loss in patients with subfoveal choroidal neovascularization (CNV) caused by AMD. Across two studies, 609 patients were randomized to treatment with verteporfin (n= 402) and placebo (n= 207) followed by laser light at 689 nm delivering 50 J/cm2.

Key Points

• A greater proportion of verteporfin treated patients lost fewer than 15 letters of visual acuity at 12-month follow-up compared to the placebo group (61% versus 46%, P < 0.001)
• In particular, patients with predominantly classic CNV lesions (>50% of the lesion) had the most notable reduction in vision loss, compared to those with 0-50%

Overall, the TAP trial is a landmark study that showed the efficacy and safety of PDT with verteporfin for treatment of CNV in classic wet AMD. And while this treatment is rarely used today due to the use of anti-VEGF medications that improve vision – not just slow vision loss – the TAP trial provided valuable information that impacted the practice of ophthalmology.und that the long-term presence of the microstent did not have a negative impact on the corneal endothelium