In this week’s issue

Wisconsin Epidemiologic Study of Diabetic Retinopathy - 1984

To develop or not to develop… a study on diabetic retinopathy. Diabetic retinopathy is the second leading cause of blindness in the United States. This population-based epidemiological study over 25 years aimed to determine the incidence, prevalence, and severity of diabetic retinopathy and visual impairment, as well as associated risk factors, in diabetic patients. The original study was 1980-1982 and there have been six patient follow-ups: 1984-86, 1990-92, 1995-96, 2000-01, 2006-07, and 2012-14. There were 996 patients with type 1 diabetes and 1370 with type 2 diabetes who were analyzed for the incidence rate and severity of diabetic retinopathy using stereoscopic color fundus photographs. 

Key Points:  

• Diabetic retinopathy was found to be related to longer duration with the disease, high levels of glycosylated hemoglobin, proteinuria, increased diastolic BP, and male sex.
• Incidence and progression of diabetic retinopathy were greatest in those who were younger at the time of diagnosis
• After 20 years of diabetes mellitus, nearly 99% of patients with type 1 and 60% with type 2 disease demonstrated some degree of diabetic retinopathy. 

Overall, after 25 years, there have been over 230 reports from the WESDR study to show glycemic control is associated with a decreased risk of diabetic retinopathy and other diabetic complications. It furthermore identified additional risk factors for diabetic retinopathy in those with diabetes.

Journal: AJOCR 

Summary written by Gautam 

The Art of Leaving Things Behind

Sometimes successful transplantation depends on what you preserve. Late endothelial failure after penetrating keratoplasty (PK) can be treated with Descemet membrane endothelial keratoplasty (DMEK). However, corneal edema can impair visualization during descemetorhexis, increasing the risk of incomplete membrane removal and an uneven surface that predisposes to graft detachment. A modified technique, DMEK with endothelial scraping without descemetorhexis (DMEK-SWD), aims to address this possibility by creating a DM-to-DM interface between the host and donor tissue.

Two patients, a 58-year-old woman and a 65-year-old man, developed endothelial failure following PK for keratoconus. Rather than stripping the host DM, surgeons scraped away dysfunctional endothelial cells within a 7.5-mm zone, preserving the underlying membrane before inserting a DMEK graft directly against it.

Both patients experienced corneal clearing and improved vision. The first patient improved from counting fingers to 20/32 at 18 months without rebubbling. The second improved from 20/125 to 20/20 at eight months, although partial graft detachment required one rebubbling. Central corneal thickness decreased from 735 to 496 μm and 653 to 501 μm, respectively.

DMEK-SWD may offer a promising alternative for failed PK grafts, but larger studies are needed to determine whether preserving host DM improves graft adherence and long-term outcomes.

During phacoemulsification in an otherwise routine cataract surgery, the surgeon notices sudden deepening of the anterior chamber, momentary pupil snap, and a fragment of lens cortex falling posteriorly. On inspection, there is a posterior capsule rupture with vitreous visible in the anterior chamber. Which of the following is the most appropriate immediate next step?

A. Carefully continue phacoemulsification to clear the remaining cortical fragments before addressing the rupture
B. Inject viscoelastic posterior to the capsular defect to tamponade the vitreous before further maneuvers
C. Immediately convert to extracapsular cataract extraction (ECCE) without further intervention
D. Perform anterior vitrectomy using the phacoemulsification handpiece’s standard irrigation/aspiration settings
E. Perform a limbal-based anterior vitrectomy using high infusion flow and low cut rate

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