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| Vol. 23, #33 • Monday, August 29, 2022 |
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Off the Cuff: Caretaker Conundrum
Directly out of my residency I began practicing at a largely geriatric practice. The type of patients I saw on a daily basis influenced the type of optometry I practice to this day: monitoring ocular complications of systemic diseases, glaucoma management, pre- and postoperative care for cornea, cataract, and retinal surgeries, and, as I’ve mentioned previously, fitting medically necessary contact lenses. These patients usually have caretakers with them sitting in the exam room’s guest chair who are typically children or spouses. I've seen these caretakers for years bringing the patient to all their visits, and yet I never see them in my exam chair. I always thought to myself that maybe they have their own eye doctors, they just can't take the time, or their own healthcare isn’t a priority to them.
As regular readers of Optometric Physician know, Arthur had surgery on August 17th, but getting to that point actually began back in January. After his primary care physician retired during the pandemic, he was establishing care with a new concierge primary care physician. All his blood work came back perfect, and he felt fine. During his visit, the doctor palpated his abdomen and asked if anything was sore; there was a mildly sore spot on his left side. He ordered an ultrasound. Even today Arthur’s new PCP says he doesn't know why he did that since everything appeared to be normal. The large mass found on Arthur’s kidney began a barrage of specialist visits, second opinions, further testing, and surgical consults on days off, early morning pre-clinic appointments, lunchtime Zoom calls, and ended with hours and days on end of sitting in hospital rooms with teams of doctors coming and going, seemingly clueless about the previous team’s recommendations.
My assumptions about the caretakers have been obliterated with my now more experienced eyes. I was wrong. I know that now. The caretakers sitting in the guest chairs aren’t ignoring their own healthcare or not making time for themselves by choice. It’s not solely a time thing at all. It's an all-consuming concern for the other, and routine care for oneself seems like an indulgence, an extravagance, a less important use of time better spent. It's easy to think or to say, "I need to take more time for myself," but entirely different in practice.
Note about Epstein: a lot of complications and procedures chasing after those complications landed him back in ICU a day after our initial downgrade. Today he's stable for the first time in a week and finally allowed to start eating…even if it's only liquids. Thank you to everyone who's expressed good thoughts and prayers. The journey continues.
Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com.
The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.
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Infectious Keratitis in Patients With Ocular Sjögren's Syndrome
These researchers performed a retrospective chart review of patients who had been followed up for ocular Sjögren's syndrome (SS) in Seoul National University Hospital from 2010 to 2020, and identified cases where infectious keratitis developed to investigate the incidence, characteristics, risk factors and treatment outcome for infectious keratitis in patients with ocular (SS). The incidence, demographic and clinical characteristics, risk factors, microbiological profiles and treatment outcome were investigated, some of which were compared with infectious keratitis cases in the non-SS group.
Out of 929 patients with ocular SS, infectious keratitis occurred in 18 eyes (1.94%). All 18 patients were female in the ocular SS group, while 48 out of 100 (48%) infectious keratitis patients were female in the non-SS group (p<0.01). The mean age at diagnosis of infectious keratitis was 66.1 years in the ocular SS group, which was not different from the non-SS group (57.2 years, p=0.12). Of the risk factors analyzed, the use of therapeutic contact lens was more frequently used in the ocular SS patients, compared to the non-SS patients (67% vs. 11%, p<0.01). Culture-positivity rate was 50% in the ocular SS group. All culture-proven cases were bacterial infections, one of which was a bacterial-fungal co-infection. Infection resolved in all eyes after the mean 29 days of medical treatment, except one that additionally required penetrating keratoplasty with vitrectomy. The visual acuity improved in 15 eyes (83%) after resolution. Infectious keratitis recurred in three patients (17%) during the mean 55.7 months of follow-up.
The incidence of infectious keratitis was 1.94% in patients with ocular SS. Most cases were bacterial infections and resolved by medical treatment. Therapeutic and visual outcomes were favorable, but recurrence occurred in 17%.
SOURCE: Kim SY, Kim SH, Yoon CH, et al. Infectious keratitis in patients with ocular Sjögren's syndrome. Korean J Ophthalmol. 2022; Aug 19. [Epub ahead of print].
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Limbal Epithelial Stem Cell Sheets From Young Donors Have Better Regenerative Potential
To investigate the stemness of limbal epithelial stem cell sheets in relation to the donor's age, human limbal explants from cadaveric donors were set on human amniotic membrane scaffolds with the xeno-free medium. Researchers evaluated limbal epithelial sheet size, expression of stem/progenitor cell markers, and colony formation efficiency from donors of different age groups (age≤45, age 45 to 65, and age>65). Expression of the proliferation marker Ki67, stem/progenitor cell markers p63α and ABCG2, cornea specific marker PANCK, and differentiation marker CK12 were evaluated to determine the effect of donor age on the storage period of limbal explant sheets. The limbal explant outgrowth sheets were stored in 4 °C for two days and analyzed for JC-1, p63α, and PANCK with FACS on each day.
From days six to 12, the outgrowth area of the limbal epithelial stem cell sheet was significantly larger in the age≤45 groups (296±54.7 mm2, day 9) compared to the other two age groups [age 45 to 65 group (278±62.6 mm2), age > 65 group (257±44 mm2), day 9] (p<0.01). In terms of stemness, outgrowth cells from aged donors (age>65) showed lower expression of stem/progenitor cell markers p63α and ABCG2 and decreased CFE compared to the other two groups. There were significantly more p63α+ cells in outgrowth cells in the age≤45 group (18.2±3.6%) compared to the age>65 group (14.1±4.6%; p<0.01). Limbal explant outgrowth sheet on the age≤45 group (32.7±7.5%) had higher percentages of cells resisting staining by JC-1 compared with sheets under the age>65 groups (25.7±7.1%, p<0.01)(JC-1low). Cells from the age≤45 group showed a higher clonogenic capacity than those from the other two age groups (4565 group, positive cells of p63α on D0, one, and two were significantly lower compared to those in the age≤45 group on the storage period.
These results suggested that donors younger than 65 years of age were a better source of limbal epithelial stem cell sheet generation with high regeneration potential.
SOURCE: Yang S, Lee HJ, Shin S, et al. Limbal epithelial stem cell sheets from young donors have better regenerative potential. Sci Rep. 2022 Aug 19;12(1):14191.
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Macular Layer Thickness and Effect of BMI, Body Fat, and Traditional Cardiovascular Risk Factors: The Tromsø Study
The purpose of this study was to investigate associations between cardiovascular risk factors and the thickness of retinal nerve fiber layer (RNFL), ganglion cell-inner plexiform layer (GCIPL), and outer retina layers (ORL). In this population-based study, investigators included participants from the Tromsø Study: Tromsø6 (2007 to 2008) and Tromsø7 (2015 to 2016). Individuals with diabetes and/or diagnosed glaucoma were excluded from this study. Retinal thickness was measured on optical coherence tomography (Cirrus HD-OCT) macula-scans, segmented on RNFL, GCIPL, and ORL, and associations were analyzed cross-sectionally (n=8288) and longitudinally (n=2595). Investigators used directed acyclic graphs (DAGs) for model selection, and linear regression to adjust for confounders and mediators in models assessing direct effects. Factors examined were age, sex, blood pressure, daily smoking, serum lipids, glycated hemoglobin, body mass index (BMI), total body fat percentage (BFP), and the adjustment variables of refraction and height.
The explained variance of cardiovascular risk factors was highest in GCIPL (0.126). GCIPL had a strong negative association with age. Women had thicker GCIPL than men at older age and thinner ORL at all ages (p<0.001). Systolic blood pressure was negatively associated with RNFL/GCIPL (p=0.001/0.004), with indication of a U-shaped relationship with GCIPL in women. The negative association with BMI was strongest in men, with a significant effect for RNFL/GCIPL/ORL (p=0.001/<0.001/0.019) and in women for GCIPL/ORL (p=0.030/0.037). BFP was negatively associated with GCIPL (p=0.01). Higher baseline BMI was associated with a reduction in GCIPL over eight years (p=0.03).
Cardiovascular risk factors explained 12.6% of the variance in GCIPL, with weight and blood pressure as the most important modifiable factors.
SOURCE: von Hanno T, Hareide LL, Småbrekke L et al. Macular layer thickness and effect of BMI, body fat, and traditional cardiovascular risk factors: the Tromsø study. Invest Ophthalmol Vis Sci. 2022; Aug 2;63(9):16.
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Industry News
Alcon to Acquire Aerie Pharmaceuticals
Alcon and Aerie Pharmaceuticals announced the companies have entered into a definitive merger agreement through which Alcon will acquire Aerie. As part of the transaction, Alcon will add the commercial products Rocklatan (netarsudil and latanoprost ophthalmic solution) 0.02%/0.005% and Rhopressa (netarsudil ophthalmic solution) 0.02%, as well as AR-15512, a Phase III product candidate for dry eye disease, and a pipeline of several clinical and preclinical ophthalmic pharmaceutical product candidates. Read more.
Visibly Becomes First FDA-Cleared Online Vision Test
Visibly, the developer of the world's first at-home digital vision testing platform, received FDA 510(k) clearance for its Visibly Digital Acuity Product (VDAP). Read more.
Glaukos Licenses Iveena Investigational Keratoconus Therapy
iVeena Delivery Systems entered into a licensing agreement with Glaukos that grants Glaukos an exclusive global license to develop and commercialize IVMED-80, a pharmacologic treatment for keratoconus. IVMED-80 is a proprietary disease-modifying topical eye drop with orphan drug designation that upregulates lysyl oxidase and induces pharmacologic corneal crosslinking to strengthen the cornea and treat keratoconus, the companies say. Read more.
Digital Diagnostics Closes $75 Million Funding Round
Digital Diagnostics—whose an autonomous AI diagnostic system, IDx-DR, is designed to detect diabetic retinopathy (including diabetic macular edema) at the point-of-care—successfully closed a $75 million Series B funding round. The company says this is the first FDA de novo-cleared autonomous AI in healthcare. Read more.
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