At the prestigious Troutman Prize ceremony on Day 1 of the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024), the spotlight shone brightly on Jason Betz (USA), a dynamic third-year medical student whose groundbreaking research in ocular pain post-refractive surgery has already made waves.
The Troutman Prize, a coveted honor celebrating the scientific prowess of emerging scholars in ophthalmology, was awarded this year to Jason Betz for his impressive work featured in the Blue Journal.
With a unique journey that began when he dabbled in computer science and chemistry at the University of Miami, Betz found his true calling in the world of eye care after crossing paths with Dr. Anat Galor. Since then, he has plunged headfirst into the depths of corneal and ocular surface research at Bascom Palmer, racking up numerous peer-reviewed publications along the way.
During his lecture, Betz cited an estimated 20% to 55% of refractive patients who, six months after surgery, are still experiencing symptoms like dryness, burning, discomfort and even photophobia. “As many of you have heard, the visual outcomes of these procedures are excellent,” said Betz, setting the stage. “But we also now know that some patients can experience persisting symptoms… And these symptoms can last six months or greater after surgery.”
So, why do some patients breeze through recovery while others are stuck with these issues? That’s the million-dollar question, and this study set out to crack the case. “We currently don’t have great data on any predictors or risk factors,” noted Betz. So, in this clinical analysis, his team zoomed in on 18 different refractive procedures to get to the root of the problem, evaluating the frequency, quality and risk factors for postoperative pain. Spoiler alert: this is just the beginning of a much larger project.
The study design
Betz’s prospective study involved 109 participants undergoing refractive surgery at two institutions: Bascom Palmer Eye Institute and the Casey Eye Institute, tracked preoperatively, as well as one-day, three-month and six-month postoperatively.
The team used a thorough assortment of questionnaires: the NRS, which rates pain on a scale from 0 to 10, the DEQ5 and OSDI, which hone in on classic dry eye symptoms and how they impact daily life, and the NPSI-eye, which pinpoints neuropathic pain symptoms like shooting pains or electric shock sensations. “We did this to try and capture all of the complaints that patients might be experiencing,” Betz explained.
Not leaving things up to patient-report alone, the researchers also collected Schirmer samples at baseline, three, and six months to measure tear production. On top of that, they performed an ocular surface exam at the three- and six-month marks, to really cover all the bases.
The big question was who fell into the “persistent pain” group—defined as having an NRS score of 3 or more at both the three and six-month follow-ups—and who got lucky with an NRS score below 3? This was the magic cut-off, based on prior research indicating that an NRS of 3 or more signals moderate pain.
The study results
So, what did Betz and his team uncover in their study? Let’s start with the big picture. Before surgery, only 7% of patients reported any ocular pain. On the day after surgery, that number shot up to 72%. Fast forward to the three- and six-month marks, though, and the numbers decreased significantly. “Eleven percent, or 12 individuals, met our criteria for persisting ocular pain symptoms at three and six months post-op,” Betz noted.
And what kind of pain were these 11% dealing with? Think soreness, grittiness, burning and pressure. Worse yet, these symptoms exacerbated with wind or light exposure.
Now, let’s talk about the risk factors for the persistent pain group. The first red flag was experiencing pain before surgery. Another was how intense the pain was one day after surgery. Depression symptoms before the procedure and using oral anti-allergy medications were also risk factors. Surprisingly, ocular surface signs of tear dysfunction—something you might expect to correlate with pain—showed absolutely no relationship to complaints. “We didn’t find any signs on our ocular surface exam that were associated with patient complaints,” Betz emphasized.
But here’s a silver lining: Despite the pain, a big chunk of patients were still pretty happy with their results. “The majority of our patients were satisfied with the results; greater than 90 percent reported complete or somewhat satisfactory visual symptoms,” Betz said.
Next steps
The next phase of Betz’s study is all about getting to the why behind those persistent pain symptoms. “We really hope to understand the why, and we’re doing this by looking at the tear samples that we’re collecting before and after surgery,” he explained.
The grand plan involves diving into the realm of tear protein biomarkers. Betz and his team are on the lookout for specific tear proteins that might hold the key to understanding who’s likely to experience pain after surgery. This could pave the way for creating diagnostic and prognostic models that will help predict various pain phenotypes and guide potential therapeutic targets.
Since their initial publication, Betz’s team have ramped up their participant pool from 109 to 280 individuals, all boasting complete six-month follow-up data. Plus, they’re actively recruiting more participants and delving into some preliminary analysis of their tear proteomics data. “Expect more exciting things from the future,” Betz teased, as he concluded his lecture.
Editor’s Note: Reporting for this story took place during the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024) from 18-21 October in Chicago, Illinois, USA.