Vitreous hemorrhage - Causes, diagnosis, and management

The Effect of Glucagon-like-Peptide-1 Receptor Agonists on Diabetic Retinopathy Progression, Central Subfield Thickness, and Response to Intravitreal Injections

Objectives: To examine the effects of glucagon-like-peptide-1 receptor agonists (GLP1-RAs) on diabetic retinopathy (DR) progression, visual acuity (VA), central subfield thickness (CST), and response to intravitreal injections (IVIs) in the Hadassah ophthalmological cohort. Methods: Of 4500 Hadassah patients with DR, 146 had a documented first course of GLP1-RA treatment lasting at least a year along with ophthalmological follow-up. Of these, 35 underwent at least two optical coherence tomography (OCT) exams with a one-year interval. These 35 GLP1-RA-naïve patients were compared to a control group of 31 patients with DR who did not receive GLP1-RA treatment. We compared demographics, medical records, ocular data, and OCT characteristics between the two study groups. Results: At baseline, patients who received GLP1-RA treatment had a significantly higher prevalence of retinal detachment and vitreous hemorrhage, as well as a higher (though not statistically significant) prevalence of cardiovascular comorbidities compared to the control group. At the end of the follow-up period, the GLP1-RA group had a higher prevalence of DR progression compared to controls (3/19 vs. 0/20, respectively; p = 0.106, Fisher's exact test), but also showed a better response to IVIs (27/35 vs. 17/31, respectively; unadjusted OR: 2.78, p = 0.058; 95% CI: [0.963, 8.020], Pearson's chi-square test). However, vitreous hemorrhage and hyperreflective retinal foci were confounding factors (adjusted IVI response OR: 1.76, p = 0.229, 95% CI: [0.553, 5.650], logistic regression). No significant differences were observed between the two groups in terms of change in visual acuity (-0.135 vs. -0.063 logMAR, respectively; p = 0.664, Student's t-test) or CST (-13.49 vs. -30.13 μm; p = 0.464, Student's t-test). Conclusions: This study presents preliminary findings showing no significant differences in DR progression, visual acuity, and CST between patients treated with GLP1-RA and control patients. Moreover, GLP1-RA therapy was not significantly associated with improved IVI response, with ocular parameters acting as confounding factors.

Should Ocular Hemorrhage Screening Be Conducted in Newborns with Acidosis?

OBJECTIVE

 Ocular hemorrhages (OHs) may cause visual disturbances and incidence vary from 18 to 39% in newborns. Precipitated/instrumental delivery and perinatal asphyxia were predefined risk factors. Acidosis can interfere with coagulation and disrupt the pressure of ocular capillaries and put infants with moderate acidosis with or without hypoxic-ischemic encephalopathy at risk for OH. We aimed to evaluate the OH in neonates with fetal acidosis.

STUDY DESIGN

Neonates >34 weeks are included if pH < 7.10 and BE <  -12 mmol/L within the first hour. Ophthalmologic examinations for retinal (RH), vitreous, and anterior chamber (hyphema) hemorrhage were done within the third day. RH was staged according to Egge's classification. Follow-up of the patients was continued until the age of 2. Clinical characteristics of newborns were analyzed.

RESULTS

 Sixty-two neonates (38 ± 2.3 weeks, 2,971 ± 612 g) were included. pH = 6.91 ± 0.16, BE = - 17.2 ± 5.3 mmol/L. OH was found in 22 (36.7%) neonates (hyphema n = 2, vitreous n = 2, RH n = 21). Thirty-eight eyes with RH were staged (Stage 3: n = 15 [39.5%]; Stage 2: n =11 [28.9%]; Stage 1: n = 12 [31.6%]). Vaginal delivery (OR: 4.9, 95% CI [1.4-17.8]) and advanced resuscitation at the delivery room (OR: 8.8; 95% CI [1.9-41.7]) were found to increase the risk of RH.

CONCLUSION

 Approximately one-third of neonates with moderate to severe acidosis exhibited RH when examined on the third day. Contrary to previous studies that reported mild RH in otherwise healthy neonates, our findings revealed that neonates with moderate to severe acidosis predominantly presented with Stage 3 RH. While the higher incidence of RH in vaginally delivered infants is consistent with previous studies, the identification of advanced resuscitation as a risk factor is a new addition to the literature. The findings in our study highlight the importance of retinal examination in neonates with acidosis in the presence of intubation during resuscitation.

KEY POINTS

· One-third of neonates with moderate to severe acidosis exhibited RH.. · Stage 3 RH was identified as the most prevalent.. · Advanced resuscitation was identified as an independent risk factor for RH..

Seeing through the strikes: a comprehensive study of ocular injuries in martial arts from 2012 to 2021

PURPOSE

Over 6 million people in the United States participate in martial arts, and the focus on striking the face poses a significant risk of injury to the eye. The objective of this study is to characterize the nature and incidence of martial arts-related eye injuries in the United States.

METHODS

A retrospective analysis of the National Electronic Injury Surveillance System (NEISS) database served as the basis of the study. The NEISS database was queried for eye injuries related to martial arts from 2012 to 2021. The entries that resulted were coded for demographic information, mechanism of injury, martial arts discipline, and diagnosis. Data were analyzed using SPSS version 28 through descriptive and χ2 analyses.

RESULTS

There were 162 reported cases of martial arts-related eye injuries in 4- to 62-years-old patients with most injuries occurring in males (84%). The most represented martial arts discipline was boxing (30.5%), and the most frequently reported mechanism of injury was punching (30.2%). The most frequently reported diagnosis resulting from eye injury was corneal abrasion (40.5%), while sight-threatening diagnoses were reported, including retinal detachment (n = 4), vitreous hemorrhage (n = 2), and open globe (n = 2).

CONCLUSIONS

Despite the significant risk of ocular injury from martial arts, corneal abrasion was the most commonly diagnosed with excellent prognosis. Sight-threatening diagnoses were also reported, indicating that martial arts athletes should be educated about the risks of eye injury and the importance of regular eye examination when practicing combat sports.

Metabolomics combined with intestinal microbiota reveals the mechanism of compound Qilian tablets against diabetic retinopathy

Background

Diabetic retinopathy (DR) is one of the common chronic complications of diabetes mellitus, which has developed into the leading cause of irreversible visual impairment in adults worldwide. Compound Qilian tablets (CQLT) is a traditional Chinese medicine (TCM) developed for treating DR, but its mechanism is still unclear. This study explored the mechanism of action of CQLT in treating DR through metabolomics and intestinal microbiota.

Methods

Histopathologic examination of the pancreas and retina of Zucker diabetic fatty (ZDF) rats and immunohistochemistry were used to determine the expression levels of retinal nerve damage indicators ionized calcium binding adaptor molecule-1 (Iba-1) and glial fibrillary acidic protein (GFAP). Rat fecal samples were tested by LC-MS metabolomics to search for potential biomarkers and metabolic pathways for CQLT treatment of DR. Characteristic nucleic acid sequences of rat intestinal microbiota from each group were revealed using 16S rDNA technology to explore key microbes and related pathways for CQLT treatment of DR. At the same time, we investigated the effect of CQLT on the gluconeogenic pathway.

Results

After CQLT intervention, islet cell status was improved, Iba-1 and GFAP expression were significantly decreased, and abnormal retinal microvascular proliferation and exudation were ameliorated. Metabolomics results showed that CQLT reversed 20 differential metabolites that were abnormally altered in DR rats. Intestinal microbiota analysis showed that treatment with CQLT improved the abundance and diversity of intestinal flora. Functional annotation of metabolites and intestinal flora revealed that glycolysis/gluconeogenesis, alanine, aspartate and glutamate metabolism, starch and sucrose metabolism were the main pathways for CQLT in treating DR. According to the results of correlation analysis, there were significant correlations between Iba-1, GFAP, and intestinal microbiota and metabolites affected by CQLT. In addition, we found that CQLT effectively inhibited the gluconeogenesis process in diabetic mice.

Conclusion

In conclusion, CQLT could potentially reshape intestinal microbiota composition and regulate metabolite profiles to protect retinal morphology and function, thereby ameliorating the progression of DR.

Nondiabetic Vitreous Hemorrhage: A Review of Management Strategy and Outcomes

Vitreous hemorrhage involves blood leakage into or around the vitreous cavity, which presents complex management decisions. Treatment options for nondiabetic vitreous hemorrhage (NDVH) traditionally include observation or early vitrectomy. Traditional guidelines have long emphasized an initial period of cautious observation. This systematic review shows that a significant portion (∼62% to 75%) of NDVH patients present a retinal tear and/or detachment upon initial presentation. B-scan ultrasonography, the primary diagnostic tool, exhibits variable sensitivities and may miss approximately half (46.4%) of underlying tears or detachments. Only 25% of observed NDVH cases clear spontaneously, while the remaining will ultimately require vitrectomy due to nonclearance (45%) or sight-threatening complications (30%). Patients under observation experience visual deficits as hemorrhage clears slowly, challenging the efficacy of traditional guidelines favoring observation. While there is no clear guideline concerning the management of NDVH, our findings suggest that early vitrectomy for severe NDVH may be the safest and most appropriate approach, provided the patient accepts procedural risks like cataract development. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Revealing new insights: Two-center evidence of microplastics in human vitreous humor and their implications for ocular health

Microplastics (MPs), an emerging environmental contaminant, have raised growing health apprehension due to their detection in various human biospecimens. Despite extensive research into their prevalence in the environment and the human body, the ramifications of their existence within the enclosed confines of the human eye remain largely unexplored. Herein, we assembled a cohort of 49 patients with four ocular diseases (macular hole, macular epiretinal membrane, retinopathy and rhegmatogenous retinal detachment) from two medical centers. After processing the samples with an optimized method, we utilized Laser Direct Infrared (LD-IR) spectroscopy and Pyrolysis Gas Chromatography/Mass Spectrometry (Py-GC/MS) to analyze 49 vitreous samples, evaluating the characteristics of MPs within the internal environment of the human eye. Our results showed that LD-IR scanned a total of 8543 particles in the composite sample from 49 individual vitreous humor samples, identifying 1745 as plastic particles, predominantly below 50 μm. Concurrently, Py-GC/MS analysis of the 49 individual samples corroborated these findings, with nylon 66 exhibiting the highest content, followed by polyvinyl chloride, and detection of polystyrene. Notably, correlations were observed between MP levels and key ocular health parameters, particularly intraocular pressure and the presence of aqueous humor opacities. Intriguingly, individuals afflicted with retinopathy demonstrated heightened ocular health risks associated with MPs. In summary, this research provides significant insights into infiltration of MP pollutants within the human eye, shedding light on their potential implications for ocular health and advocating for further exploration of this emerging health risk.

Intra-Anterior Chamber Injection of Ranibizumab in Advanced Pediatric Vitreoretinal Diseases

Importance

Anti-vascular endothelial growth factor (VEGF) treatment through intravitreal or subretinal administrations has been proven effective for VEGF-driven pediatric vitreoretinal diseases but are not feasible for advanced cases, such as shallow traction retinal detachments or peripheral circumferential retinal detachments which adhere to the lens. Intra-anterior chamber injection (IAcI) of anti-VEGF may be a viable alternative in such cases but needs evaluation.

Objective

To investigate the effects and safety of IAcI of anti-VEGF to treat VEGF-driven pediatric vitreoretinal diseases.

Design, Setting, and Participants

This was a retrospective observational case series study conducted at Xinhua Hospital, affiliated with Shanghai Jiao Tong University School of Medicine in China. The study included 14 eyes of 13 children diagnosed with vitreoretinal disease exhibiting elevated vascular activity between January and August 2023.

Intervention

IAcI with ranibizumab.

Main Outcomes and Measures

Retinal vascular abnormalities, vitreous hemorrhage resolution, and complications 1 month and 3 months after injection.

Results

Of 13 patients included in this study, 12 were male. The mean age was 4.6 years (range, 1 month to 9 years). Six patients were diagnosed with familial exudative vitreoretinopathy, 4 with morning glory syndrome, 1 with retinopathy of prematurity, and 2 with chronic retinal detachments of unknown causes. At 1-month postoperative follow-up, vascular activity had decreased in 14 of 14 eyes. At 3-month follow-up, vascular activity had resolved in 7 of 14 eyes, persisted in 6 of 14 eyes, and reactivated in 1 of 14 eyes. On final observation, no complications were reported.

Conclusions and Relevance

These findings support the possibility of treatment using IAcI with ranibizumab to decrease retinal vascular abnormalities in familial exudative vitreoretinopathy or retinopathy of prematurity or related conditions, but further studies are needed to understand more precise benefits and risks. This approach might be considered in cases where intravitreal or subretinal injection are not feasible, recognizing the limitations of these findings and that longer-term outcomes still need to be monitored.

Risk factors for proliferative vitreoretinopathy after retinal detachment surgery: A systematic review and meta-analysis

BACKGROUND

To comprehensively investigate risk factors for proliferative vitreoretinopathy (PVR) after retinal detachment (RD) surgery.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were systematically searched until May 22, 2023. Risk factors included demographic and disease-related risk factors. Odds ratios (ORs) and weighted mean differences (WMDs) were used as the effect sizes, and shown with 95% confidence intervals (CIs). Sensitivity analysis was conducted. The protocol was registered with PROSPERO (CRD42022378652).

RESULTS

Twenty-two studies of 13,875 subjects were included in this systematic review and meta-analysis. Increased age was associated with a higher risk of postoperative PVR (pooled WMD = 3.98, 95%CI: 0.21, 7.75, P = 0.038). Smokers had a higher risk of postoperative PVR than non-smokers (pooled OR = 5.07, 95%CI: 2.21-11.61, P<0.001). Presence of preoperative PVR was associated with a greater risk of postoperative PVR (pooled OR = 22.28, 95%CI: 2.54, 195.31, P = 0.005). Presence of vitreous hemorrhage was associated with a greater risk of postoperative PVR (pooled OR = 4.12, 95%CI: 1.62, 10.50, P = 0.003). Individuals with aphakia or pseudophakia had an increased risk of postoperative PVR in contrast to those without (pooled OR = 1.41, 95%CI: 1.02, 1.95, P = 0.040). The risk of postoperative PVR was higher among patients with macula off versus those with macula on (pooled OR = 1.85, 95%CI: 1.24, 2.74, P = 0.002). Extent of RD in patients with postoperative PVR was larger than that in patients without (pooled WMD = 0.31, 95%CI: 0.02, 0.59, P = 0.036). Patients with postoperative PVR had longer duration of RD symptoms than those without (pooled WMD = 10.36, 95%CI: 2.29, 18.43, P = 0.012).

CONCLUSION

Age, smoking, preoperative PVR, vitreous hemorrhage, aphakia or pseudophakia, macula off, extent of RD, and duration of RD symptoms were risk factors for postoperative PVR in patients undergoing RD surgery, which may help better identify high-risk patients, and provide timely interventions.

Early versus Late Pars Plana Vitrectomy in Vitreous Hemorrhage: A Systematic Review

Background: Vitreous hemorrhage (VH) is a common vitreoretinal condition causing impairment of vision due to various etiologies. No consensus exists on the best timing for performing pars plana vitrectomy (PPV) in fundus-obscuring VH. Materials and Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, we conducted a systematic review of the timing of PPV in VH. We assessed the strength of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for all the included publications, in accordance with the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) recommendations. Results: A total of 1731 articles were identified. Following the removal of duplicates and screening of abstracts, 1203 articles remained. Subsequently, a comprehensive full-text review of 30 articles was conducted. Ultimately, 18 articles met the predefined inclusion criteria. Conclusions: Despite the small number of studies on the timing of treatment for VH, the advantage of early over late PPV seems to be a reasonable approach in selected cases, and it might be considered modern standard care.

Ophthalmologic Emergencies: Assessment and Management

There are an estimated 2-3 million emergency department (ED) visits in the United States for eye complaints. Although most patients who present to the ED have nontraumatic eye complaints, many seek treatment for eye trauma, which is a leading cause of unilateral blindness and vison impairment. Given the prevalence of eye-related emergencies, it is imperative that emergency care providers understand how to recognize and treat eye complaints to prevent permanent vision loss and disability. This article covers basic eye anatomy and physiology, discusses a systematic approach to the eye examination, and presents the evidence-based treatment of selected, common nonemergent and emergent eye complaints. For each complaint, essential history questions, examination techniques, differentials, and emergency management have been presented.