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Miller SC, Meeralakshmi P, Fliotsos MJ, Justin GA, Yonekawa Y, Chen A, Hoskin AK, Blanch RJ, Cavuoto KM, Low R, Li X, Gardiner M, Liu TYA, Shah AS, Auran JD, Agrawal R, Woreta FA. Global Current Practice Patterns for the Management of Hyphema. Clin Ophthalmol 2022; 16:3135-3144. [PMID: 36187914 PMCID: PMC9524379 DOI: 10.2147/opth.s372273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/20/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide. Methods A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution. Results For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution. Conclusion Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.
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Affiliation(s)
- Sarah C Miller
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Michael J Fliotsos
- Department of Ophthalmology, Yale New Haven Hospital, New Haven, CT, USA
| | - Grant A Justin
- Vitreoretinal Surgery Service, Duke Eye Center, Durham, NC, USA
| | - Yoshihiro Yonekawa
- Wills Eye Hospital, Mid Atlantic Retina, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Ariel Chen
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Annette K Hoskin
- Save Sight Institute, University of Sydney, Sydney, Australia
- Lions Eye Institute, University of Western Australia, Perth, Austral
ia
| | - Richard J Blanch
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England
- University Hospitals Birmingham, NHS Foundation Trust, Birmingham, England
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, England
| | - Kara M Cavuoto
- Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Rebecca Low
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ximin Li
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - T Y Alvin Liu
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ankoor S Shah
- Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James D Auran
- Columbia University Irving Medical Center, New York City, NY, USA
| | - Rupesh Agrawal
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore
- Singapore Eye Research Institute, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Duke NUS Medical School, Singapore
- Rupesh Agrawal, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore Eye Research Institute, Lee Kong Chian School of Medicine, Nanyang Technological University, Duke NUS Medical School, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore, Tel +6563571000, Email
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Correspondence: Fasika A Woreta, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21205, USA, Tel +410-961-2868, Fax +410-614-9632, Email
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Dornhorst A, Frost G. The principles of dietary management of gestational diabetes: reflection on current evidence. J Hum Nutr Diet 2002; 15:145-56; quiz 157-9. [PMID: 11972744 DOI: 10.1046/j.1365-277x.2002.00344.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Gestational diabetes (GDM) is the commonest metabolic disorder of pregnancy. Most women with GDM are treated with nutritional management alone. There are conflicting guidelines surrounding its dietary management and this has resulted in a lack of conformity to the dietary advice currently prescribed. There is also conflicting opinions to the effectiveness of dietary management of GDM on pregnancy outcomes. The aim of this review was to examine the scientific evidence for the optimal nutritional management of GDM. METHODS A Medline search of all English papers published between 1995 and 2001 that cross-referenced GDM with diet was under taken. Because of the poor quality of many of these papers, literature prior to 1995 known to the authors and considered relevant to the review were also included. RESULTS The evidence base in this area is of poor quality. One systematic review based on randomized control trials failed to show any benefit from dietary intervention in GDM. However, that review did not include informative clinical and observational studies that are not classified as randomized controlled trials. Overall current evidence points to the effectiveness of dietary advice as a means of improving maternal hyperglycaemia and reducing the risk of accelerated foetal growth. The evidence surrounding energy restriction, carbohydrate and fat manipulation in GDM remains controversial. CONCLUSIONS Current but limited evidence supports dietary alterations to reduce rates of accelerated foetal growth. There is a clear need for good quality randomized control trials in this area.
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Affiliation(s)
- A Dornhorst
- Nutrition & Dietetic Research Group, Department of Metabolic Medicine and Nutrition & Dietetics, Division of Investigative Science, Hammersmith Hospital Campus, Faculty of Medicine, Imperial School of Medicine, London, UK
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Abstract
Chemical injuries of the eye may produce extensive damage to the ocular surface epithelium, cornea, and anterior segment, resulting in permanent unilateral or bilateral visual impairment. Pathophysiological events which may influence the final visual prognosis and which are amenable to therapeutic modulation include 1) ocular surface injury, repair, and differentiation, 2) corneal stromal matrix injury, repair and/or ulceration, and 3) corneal and stromal inflammation. Immediately following chemical injury, it is important to estimate and clinically grade the severity of limbal stem cell injury (by assessing the degree of limbal, conjunctival, and scleral ischemia and necrosis) and intraocular penetration of the noxious agent (by assessing clarity of the corneal stroma and anterior segment abnormalities). Immediate therapy is directed toward prompt irrigation and removal of any remaining reservoir of chemical contact with the eye. Initial medical therapy is directed promoting re-epithelialization and transdifferentiation of the ocular surface, augmenting corneal repair by supporting keratocyte collagen production and minimizing ulceration related to collagenase activity, and controlling inflammation. Early surgical therapy if indicated, is directed toward removal of necrotic corneal epithelium and conjunctiva, prompt re-establishment of an adequate limbal vascularity, and re-establishment of limbal stem cell population early in the clinical course, if sufficient evidence exists of complete limbal stem cell loss. Re-establishment of limbal stem cells by limbal autograft or allograft transplantation, or by transfer in conjunction with large diameter penetrating keratoplasty, may facilitate development of an intact, phenotypically correct corneal epithelium. Limbal stem cell transplantation may prevent the development of fibrovascular pannus or sterile corneal corneal ulceration, simplify visual rehabilitation, and improve the visual prognosis. Advances in ocular surface transplantation techniques which allow late attempts at visual rehabilitation of a scarred and vascularized cornea include limbal stem cell transplantation for incomplete transdifferentiation and persistent corneal epithelial dysfunction, and conjunctival and/or mucosal membrane transplantation for ocular surface mechanical dysfunction. Rehabilitation of the ocular surface may be followed, if necessary, by standard penetrating keratoplasty if all aspects of ocular surface rehabilitation are complete, or by large diameter penetrating keratoplasty if successful limbal stem cell transplantation cannot be achieved but other ocular surface rehabilitation is complete.
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Affiliation(s)
- M D Wagoner
- Anterior Segment/External Disease Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
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