The edition · Ophthalmology
A retinal safety signal for a cardiovascular drug class
Genetically proxied inhibition of cholesteryl ester transfer protein tracked with higher macular degeneration risk in two ancestries, and three times higher for exudative disease in East Asians. Plus 240 degrees of goniotomy matching 360 with half the hyphema, and what a corneal graft does to the pressure.
The edition in brief
A drug-target Mendelian randomisation study in 457,242 UK Biobank participants and 7,058 Singaporean participants found greater genetically proxied cholesteryl ester transfer protein inhibition associated with higher risk of advanced age-related macular degeneration (OR 1.45, 95% CI 1.25-1.67) and early disease (1.29, 1.19-1.41) in Europeans, and with exudative macular degeneration (3.14, 2.16-4.57), typical neovascular disease (2.84, 1.69-4.79) and polypoidal choroidal vasculopathy (3.18, 2.05-4.93) in East Asians. The authors call it a potential retinal safety signal needing trial validation. A prospective multicentre study of 126 eyes with juvenile open-angle glaucoma across 19 Chinese centres compared goniotomy arc sizes. Complete success at 12 months was 13.3% for 120 degrees, 55.3% for 240 and 64.7% for 360; the two larger arcs did not differ from each other but both beat 120 degrees. Hyphema occurred in 64.7% of the 360-degree group against 34.0% at 240 and 31.1% at 120. In 2,655 pressure measurements from 154 eyes with stable treated primary open-angle glaucoma, ambient temperature was negatively associated with intraocular pressure (estimate -0.029, P = 0.003) and mean blood pressure positively (0.021, P < 0.001). Twenty-eight pseudophakic Indian eyes with mild to moderate open-angle glaucoma implanted with a trabecular micro-bypass stent had mean pressure fall from 21.14 to 15.14 mmHg at 18 months, with medications reduced from 2.07 to 1.18. A meta-analysis of 33 studies and 5,235 eyes found de novo glaucoma in 3% after Descemet membrane endothelial keratoplasty against 11% after the automated stripping procedure, at low to very low certainty.
Genetically proxied CETP inhibition tracked with macular degeneration
A genetic analysis raises a retinal safety question about cholesteryl ester transfer protein inhibition, but it is not a reason to change any patient's lipid treatment.
In juvenile glaucoma, 240 degrees of goniotomy matched 360 with half the hyphema
Consider a 240-degree goniotomy in juvenile open-angle glaucoma — observed efficacy matched 360 degrees with roughly half the hyphema and no consumable.
Pressure ran lower when it was warmer, and higher when blood pressure was up
A small part of visit-to-visit pressure variation is weather and blood pressure rather than disease — judge escalation on a trend, not a single seasonal reading.
Indian data on a standalone trabecular micro-bypass stent in pseudophakic eyes
A standalone trabecular micro-bypass stent lowered pressure by about 6 mmHg and removed about one drop at 18 months in Indian pseudophakic eyes — promising, but uncontrolled.
No eye gets a pressure-lowering drop before the angle has been seen
Do gonioscopy, in a dim room with a dim narrow beam off the pupil, before any eye is started on pressure-lowering treatment — and indent where the angle looks closed.
Glaucoma and raised pressure are common after endothelial keratoplasty, and less so after DMEK
Build pressure monitoring and active steroid review into follow-up after every endothelial keratoplasty — a third of eyes after the automated stripping procedure developed ocular hypertension.
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