Mechanism and outcomes of recreational and sports-related open globe injuries

OBJECTIVES

To describe the mechanisms and visual outcomes of recreational and sports-related open globe injuries (OGIs).

METHODS

A retrospective case series of eyes experiencing OGI secondary to recreational and sports-related activities at Memorial Hermann Hospital - Texas Medical Center (MHH-TMC) from January 1st, 2010 through March 31st, 2015 was conducted. Exclusionary criteria included no documented ophthalmologic examination upon presentation and repairs performed by services other than ophthalmology. A two-tailed t-test and Fisher's exact test were utilized to assess for statistical significance (p < 0.05).

RESULTS

A total of 20 eyes from 20 patients experiencing OGIs secondary to recreational and sports-related activities were included. Thirteen eyes (65 %) presented with OGIs from penetrating objects while seven eyes (35 %) had injuries from blunt injuries. Males comprised most of the total study group (17 of 20 patients), and zone 3 injuries were the most common location of OGI. While eyes with OGIs from blunt trauma underwent evisceration/enucleation procedures more frequently than OGIs from penetrating mechanisms (71% vs 23 %) (p = 0.10), the final visual outcomes were similarly poor between groups. Only three eyes in this series experienced an improvement from baseline VA; all three eyes had lacked initial findings consistent with severe injury.

CONCLUSIONS

Recreational and sports related OGIs most commonly occur in zone 3 and in young males, regardless of injury type. OGIs due to both penetrating and blunt trauma mechanisms implicate poor functional outcomes, but the absence of certain presenting injury features may indicate possibility of eventual visual recovery.

Retrospective Analysis of Radiation-Induced Complications of Uveal Melanoma Patients Treated With Brachytherapy in the Era of Anti-VEGF

PURPOSE

To associate clinical factors and radiation doses delivered by iodine-125 plaque brachytherapy to visual outcomes and development of radiation-induced ocular complications in patients with uveal melanoma in the era of anti-vascular endothelial growth factor (anti-VEGF) injections.

DESIGN

Retrospective cohort study.

METHODS

A retrospective chart review was performed for 225 patients treated with iodine-125 brachytherapy for uveal melanoma. The effects of radiation doses (focal doses, average dose to the entire eye, and integral dose) on visual outcomes and development of radiation complications (radiation retinopathy, radiation optic neuropathy, vitreous hemorrhage, and neovascular glaucoma) were analyzed using multivariate Cox regression snalysis.

RESULTS

Median follow-up was 33.6 months (range, 12-105.6 months). Radiation retinopathy was associated with younger age, tumor distance to optic nerve <6 mm, and maximum radiation dose to fovea. Radiation optic neuropathy was associated with White race, tumor distance to optic nerve <6 mm, and integral radiation dose. Vitreous hemorrhage was associated with White race and integral radiation dose. Incidence of neovascular glaucoma was low in our study, with 2 patients (0.9%) developing the complication. Of the 123 patients who developed radiation retinopathy, 82 patients (66.7% of radiation retinopathy patients, 37.3% of total patients) received anti-VEGF injections.

CONCLUSIONS

Our study found multiple associations between radiation doses and complications as well as visual outcomes on multivariate analysis. Given that the majority of our patients who developed radiation retinopathy received anti-VEGF injections, our study helps to illustrate the course and progression of radiation-induced complications in the new era of anti-VEGF.

Synaptic Origins of the Complex Receptive Field Structure in Primate Smooth Monostratified Retinal Ganglion Cells

Considerable progress has been made in studying the receptive fields of the most common primate retinal ganglion cell (RGC) types, such as parasol RGCs. Much less is known about the rarer primate RGC types and the circuitry that gives rise to noncanonical receptive field structures. The goal of this study was to analyze synaptic inputs to smooth monostratified RGCs to determine the origins of their complex spatial receptive fields, which contain isolated regions of high sensitivity called "hotspots." Interestingly, smooth monostratified RGCs co-stratify with the well-studied parasol RGCs and are thus constrained to receiving input from bipolar and amacrine cells with processes sharing the same layer, raising the question of how their functional differences originate. Through 3D reconstructions of circuitry and synapses onto ON smooth monostratified and ON parasol RGCs from central macaque retina, we identified four distinct sampling strategies employed by smooth and parasol RGCs to extract diverse response properties from co-stratifying bipolar and amacrine cells. The two RGC types differed in the proportion of amacrine cell input, relative contributions of co-stratifying bipolar cell types, amount of synaptic input per bipolar cell, and spatial distribution of bipolar cell synapses. Our results indicate that the smooth RGC's complex receptive field structure arises through spatial asymmetries in excitatory bipolar cell input which formed several discrete clusters comparable with physiologically measured hotspots. Taken together, our results demonstrate how the striking differences between ON parasol and ON smooth monostratified RGCs arise from distinct strategies for sampling a common set of synaptic inputs.

Sources of Calcium at Connexin 36 Gap Junctions in the Retina

Synaptic plasticity is a fundamental feature of the CNS that controls the magnitude of signal transmission between communicating cells. Many electrical synapses exhibit substantial plasticity that modulates the degree of coupling within groups of neurons, alters the fidelity of signal transmission, or even reconfigures functional circuits. In several known examples, such plasticity depends on calcium and is associated with neuronal activity. Calcium-driven signaling is known to promote potentiation of electrical synapses in fish Mauthner cells, mammalian retinal AII amacrine cells, and inferior olive neurons, and to promote depression in thalamic reticular neurons. To measure local calcium dynamics in situ, we developed a transgenic mouse expressing a GCaMP calcium biosensor fused to Connexin 36 (Cx36) at electrical synapses. We examined the sources of calcium for activity-dependent plasticity in retina slices using confocal or Super-Resolution Radial Fluctuations imaging. More than half of Cx36-GCaMP gap junctions responded to puffs of glutamate with transient increases in fluorescence. The responses were strongly dependent on NMDA receptors, in keeping with known activity-dependent signaling in some amacrine cells. We also found that some responses depended on the activity of voltage-gated calcium channels, representing a previously unrecognized source of calcium to control retinal electrical synaptic plasticity. The high prevalence of calcium signals at electrical synapses in response to glutamate application indicates that a large fraction of electrical synapses has the potential to be regulated by neuronal activity. This provides a means to tune circuit connectivity dynamically based on local activity.

Postoperative Complications of True Dropless Cataract Surgery versus Standard Topical Drops

Purpose  Compare postoperative outcomes in cataract surgery between eyes with standard drop regimen versus dropless protocol by residents. Design  Retrospective cohort study between April 1, 2018 and March 31, 2020. Methods  The study was performed at Lyndon B. Johnson General Hospital in Houston, Harris County, Texas. A total of 547 eyes (234 dropless vs. 313 standard) with phacoemulsification cataract surgery and minimum of 1-month follow-up with best-corrected visual acuity (BCVA) were included. Dropless received 40 mg sub-Tenon's triamcinolone and intracameral moxifloxacin. Patients were followed at postoperative day 1 (POD1), week 1 (POW1), and month 1 (POM1). Postoperative rate of BCVA better than 20/40 (Good vision) and rate of complications were compared between groups. Results  Good vision on POM1 in dropless (77.8%) was noninferior to standard (75.1%, p  = 0.80). Complication rate in dropless (28.6%) was noninferior to standard (24.0%, p  = 0.13). Intraocular pressure (IOP) elevation on POD1 ( p  = 0.041) and anterior chamber (AC) cells on POW1 and POM1 ( p  < 0.001) were more frequent in dropless. Mean spherical equivalent at POM1 was better in dropless (-0.37 D [±0.81 D]) compared with standard (-0.61D [±0.77 D], p  = 0.001). Early posterior capsular opacification (early PCO) was more frequent in dropless ( p  = 0.042). Conclusions  Postoperative rate of BCVA better than 20/40 and rate of postoperative complications were noninferior, although dropless had higher rates of AC inflammation, IOP elevation, and early PCO.

Direct Costs of Second Aqueous Shunt Implant Versus Transscleral Cyclophotocoagulation (The Assists Trial)

PRCIS

The cost of cyclophotocoagulation is less than the cost of a second glaucoma drainage device.

PURPOSE

To compare the total direct costs of implantation of a second glaucoma drainage device (SGDD) with transscleral cyclophotocoagulation (CPC) for patients with inadequately controlled intraocular pressure (IOP) reduction, despite the presence of a preexisting glaucoma drainage device in the ASSISTS clinical trial.

METHODS

We compared the total direct cost per patient, including the initial study procedure, medications, additional procedures, and clinic visits during the study period. The relative costs for each procedure during the 90-day global period and the entire study period were compared. The cost of the procedure, including facility fees and anesthesia costs, were determined using the 2021 Medicare fee schedule. Average wholesale prices for self-administered medications were obtained from AmerisourceBergen.com. The Wilcoxon rank sum test was used to compare costs between procedures.

RESULTS

Forty-two eyes of 42 participants were randomized to SGDD (n=22) or CPC (n=20). One CPC eye was lost to follow-up after initial treatment and was excluded. The mean (±SD, median) duration of follow-up was 17.1 (±12.8, 11.7) months and 20.3 (±11.4, 15.1) months for SGDD and CPC, respectively ( P =0.42, 2 sample t test). The mean total direct costs (±SD, median) per patient during the study period were $8790 (±$3421, $6805 for the SGDD group) and $4090 (±$1424, $3566) for the CPC group ( P <0.001). Similarly, the global period cost was higher in the SGDD group than in the CPC group [$6173 (±$830, $5861) vs. $2569 (±$652, $2628); P <0.001]. The monthly cost after the 90-day global period was $215 (±$314, $100) for SGDD and $103 (±$74, $86) for CPC ( P =0.31). The cost of IOP-lowering medications was not significantly different between groups during the global period ( P =0.19) or after the global period ( P =0.23).

CONCLUSION

The total direct cost in the SGDD group was more than double that in the CPC group, driven largely by the cost of the study procedure. The costs of IOP-lowering medications were not significantly different between groups. When considering treatment options for patients with a failed primary GDD, clinicians should be aware of differences in costs between these treatment strategies.

Comparison between the CASIA SS-1000 and Pentacam in measuring corneal curvatures and corneal thickness maps

PURPOSE

To compare the intra-device repeatability and inter-device reproducibility between two anterior segment imaging instruments, the CASIA SS-1000 (Tomey Corp., Nagoya, Japan) and Pentacam (OCULUS, Arlington, WA) in measuring anterior segment parameters.

METHODS

Single-center, prospective clinical trial. Participants ≥20 years of age were included. One eye was randomly selected, each imaged by three CASIA SS-1000 devices and three Pentacam devices by three different examiners. Each photographer operated a pair of devices, one CASIA SS-1000 and one Pentacam. The image order for each participant was determined by a random permutation table. Three images were taken from each device. A total of 18 images were taken for each eye. Ratios of the standard deviations, referenced as (CASIA/Pentacam), were calculated to compare the repeatability and reproducibility of the two imaging instruments.

RESULTS

In all, 66 participants with a mean age of 46.4 years (±21.7) were enrolled in the study. All repeatability ratios and intra-device variability were less than 1 (anterior corneal curvature: flat = 0.86, steep = 0.85; posterior corneal curvature: flat = 0.43, steep = 0.61; and map: thinnest = 0.22; central = 0.24, 2 mm = 0.26, 4 mm = 0.27, and 6 mm = 0.30). All reproducibility ratios, which measure the inter-device variability, were less than 1 (anterior corneal curvature: flat = 0.58, steep = 0.73; posterior corneal curvature: flat = 0.25, steep = 0.31; and pachymetry map: thinnest = 0.20; central = 0.20; 2 mm = 0.20; 4 mm = 0.19; and 6 mm = 0.22). A ratio of less than 1 indicates that the CASIA SS-1000 has more consistent measurements.

CONCLUSIONS

The CASIA SS-1000 was found to have better repeatability and reproducibility compared to the Pentacam for both corneal curvature and pachymetry maps. This greater consistency may require further study to determine whether the decreased variability can be translated into improved clinical results.

Non-traumatic open globe injuries: presenting characteristics and visual outcomes

PURPOSE

To describe clinical characteristics and visual outcomes of non-traumatic open globe injuries.

SETTING

A level 1 trauma centre in a large urban medical centre.

DESIGN

Retrospective study.

METHODS

Charts of non-traumatic open globe patients admitted to MHH-TMC from 1/2010 to 3/2015 were reviewed for demographics, cause, clinical characteristics, visual acuity (VA) and enucleation.

RESULTS

Thirty eyes were included: 15 (50%) were males with a mean age of 47 (±28) years. All presented with zone 1 injury. Twenty-five (83%) had a perforated corneal ulcer. Presenting VA was count fingers (n = 3, 10%) to NLP (n = 6, 20%). Twenty-four (80%) involved infection, 5 (17%) congenital, 3 (10%) chemical burn and 2 (7%) neurotrophic. Conjunctival injection (n = 22, 77%), corneal opacification (n = 20, 71%) and relative afferent pupillary defect (n = 9, 44%) were common. After treatment, 23 (88%) were worse than 6/60 (20/200), 9 (35%) were NLP and 8 (27%) required enucleation.

CONCLUSIONS

Often non-traumatic open globe injuries are zone 1 and due to perforated infectious ulcers. Compared to previously reported traumatic injuries, these have higher rates of enucleation (27% vs 8%) and poorer final VA (88% vs 68% worse than 6/60 20/200).

Outcomes of the Second Aqueous Shunt Implant Versus Transscleral Cyclophotocoagulation Treatment Study: A Randomized Comparative Trial

PRCIS

Short-term overall success rates were high with either SGDD or CPC. However, SGDD was associated with more clinic visits and an increased risk of additional glaucoma surgery. Both treatments were reasonable options for eyes with inadequately controlled IOP after a single GDD.

PURPOSE

The purpose of this study is to compare the implantation of a second glaucoma drainage device (SGDD) and transscleral cyclophotocoagulation (CPC) in eyes with inadequately controlled intraocular pressure (IOP), despite the presence of a preexisting glaucoma drainage device.

METHODS

Patients with inadequately controlled IOP, despite the medical therapy and a preexisting glaucoma drainage device, were enrolled at 14 clinical centers and randomly assigned to treatment with a SGDD or CPC.

MAIN OUTCOME MEASURES

Surgical failure was defined as: (1) IOP ≤5 mm Hg or >18 mm Hg or <20% reduction below baseline on maximum tolerated topical ocular hypotensive therapy, (2) reoperation for glaucoma, or (3) loss of light perception. The primary outcome measure was overall success with or without adjunctive medical therapy.

RESULTS

Forty-two eyes of 42 participants were randomized to SGDD (n=22) or CPC (n=20). Mean duration of follow-up was 18.6 (±12.1; range: 1.1-38.6) months. The cumulative success rate was 79% for SGDD and 88% for CPC at 1 year ( P =0.63). Although the study was underpowered, no significant differences in IOP, postoperative number of IOP-lowering medications, or adverse events were observed. The number of additional glaucoma surgeries ( P =0.003), office visits during the first 3 months ( P <0.001), and office visits per month after month 3 ( P <0.001) were greater in the SGDD group.

CONCLUSIONS

Short-term overall success rates were high with either SGDD or CPC. However, SGDD was associated with more clinic visits and an increased risk of additional glaucoma surgery.

Prognosticators of Visual Acuity After Indirect Traumatic Optic Neuropathy

BACKGROUND

The purpose of this study is to determine whether there are radiographic and systemic clinical characteristics that can predict final visual outcomes in patients with indirect traumatic optic neuropathy (iTON).

METHODS

This study is a retrospective, multicenter case series of adult patients with iTON treated initially at large, urban, and/or academic trauma centers with follow-up at an affiliated ophthalmology clinic. In addition to detailed cranial computed tomography characteristics, demographics, systemic comorbidities, coinjuries, blood products administered, and intracranial pressure, along with other factors, were gathered. LogMAR visual acuity (VA) at the initial presentation to the hospital and up to 12 months follow-up was collected.

RESULTS

Twenty patients met inclusion criteria; 16 (80%) were men with a mean age of 40.9 years (±20.9). Mean initial VA was 1.61 logMAR (∼20/800, ± 0.95), and final VA was 1.31 logMAR (∼20/400, ± 1.06). Three patients (4 eyes) had no light perception (NLP) VA at presentation and remained NLP at final follow-up. Of the predictors analyzed, only the initial VA was found to be a significant predictor of visual outcome. The presence of orbital fractures, intraconal and/or extraconal hemorrhage, as well as systemic comorbidities, were not found to significantly affect visual outcome.

CONCLUSIONS

After evaluating multiple factors, initial VA was the only factor associated with visual prognosis in iTON. This knowledge may better enable clinicians to predict visual prognosis and set reasonable expectations with patients and families at the time of injury.

Synaptic inputs to broad thorny ganglion cells in macaque retina

In primates, broad thorny retinal ganglion cells are highly sensitive to small, moving stimuli. They have tortuous, fine dendrites with many short, spine-like branches that occupy three contiguous strata in the middle of the inner plexiform layer. The neural circuits that generate their responses to moving stimuli are not well-understood, and that was the goal of this study. A connectome from central macaque retina was generated by serial block-face scanning electron microscopy, a broad thorny cell was reconstructed, and its synaptic inputs were analyzed. It received fewer than 2% of its inputs from both ON and OFF types of bipolar cells; the vast majority of its inputs were from amacrine cells. The presynaptic amacrine cells were reconstructed, and seven types were identified based on their characteristic morphology. Two types of narrow-field cells, knotty bistratified Type 1 and wavy multistratified Type 2, were identified. Two types of medium-field amacrine cells, ON starburst and spiny, were also presynaptic to the broad thorny cell. Three types of wide-field amacrine cells, wiry Type 2, stellate wavy, and semilunar Type 2, also made synapses onto the broad thorny cell. Physiological experiments using a macaque retinal preparation in vitro confirmed that broad thorny cells received robust excitatory input from both the ON and the OFF pathways. Given the paucity of bipolar cell inputs, it is likely that amacrine cells provided much of the excitatory input, in addition to inhibitory input.

Anterior chamber lens sizing: Comparison of white-to-white and scleral spur-to-scleral spur methods

PURPOSE

To determine the most accurate method of estimating scleral-spur-to-scleral-spur (STS) distance for ophthalmologists without access to an anterior chamber optical coherence tomography (AS-OCT) instrument when selecting an anterior chamber intraocular lens (AC IOL).

SETTING

Robert Cizik Eye Clinic, Houston, TX.

DESIGN

Prospective cohort study.

METHODS

The eyes of 65 participants aged 18 years or older were imaged by the Lenstar LS 900 optical biometer and CASIA SS-1000 swept-source Fourier-domain AS-OCT. Eyes were excluded if the anterior segment anatomy was significantly altered and the angle could not be visualized. When both eyes were eligible, 1 eye was randomly selected. The white-to-white (WTW) distance, STS distance, and axial length were recorded and compared. The difference between STS and horizontal WTW was calculated for each meridian. The mean (±SD) differences, 95% limits of agreement, and Bland-Altman agreement were computed for each pair of STS and WTW measurements.

RESULTS

The study comprised 65 eyes of 65 participants. In nearly every case, WTW + 0.5 and WTW + 1 overestimated STS. The horizontal WTW without adjustment was the best predictor of STS. The WTW best corresponded to the vertical STS meridian (6 to 12 o'clock) and not the horizontal meridian (3 to 9 o'clock), along which AC IOLs are traditionally placed.

CONCLUSIONS

The horizontal WTW method without an adjustment factor most accurately estimated STS distance and should be used to select AC IOL size when AS-OCT is not available. If AS-OCT is available, it should be used instead. In addition, AC IOLs should be placed in a vertical orientation rather than the traditional horizontal orientation to minimize sizing errors.

Heading-Related Slowing by Twenty-Four Hours in Youth Athletes

Research suggests cumulative effects of repetitive head impacts (RHIs) on brain structure, especially with younger age of first exposure. Further, recent evidence suggests no immediate cognitive changes with increased RHIs but impairments across a sports season. The aim was to examine more closely the short-term time course of behavioral effects of exposure to RHI. Across 2 years, 18 female adolescent soccer players were tested on ProPoint (sensorimotor) and AntiPoint (cognitive) tasks with reaction time (RT) being the main outcome measure. The athletes were tested before and after workout with ball heading (immediate effect), as well as 24 h after workout (24 h effect) throughout two consecutive seasons. The number of headers performed 24 h before workout, during workout, and season average per workout were recorded. The athletes showed a decrease in ProPoint and AntiPoint RTs immediately after a workout, with no change or decrease in RTs with increasing RHIs. However, increasing RHIs during workout increased RTs in both tasks when tested 24 h later. The athletes also showed an increase in AntiPoint RTs with increasing season average RHIs. Our findings show a complex time course of effects of RHIs on sensorimotor and cognitive performance in adolescent athletes, with exposure to RHIs associated with no change or immediate benefits and then deficits by 24 h. Pathophysiological changes associated with exercise and traumatic brain injury can account for the sensorimotor and cognitive performance changes occurring within 24 h after RHIs.

Differential benefits of olanzapine on executive function in schizophrenia patients: Preliminary findings

OBJECTIVE

Schizophrenia patients show executive function (EF) impairments in voluntary orienting as measured by eye-movements. We tested 14 inpatients to investigate the effects of the antipsychotic olanzapine on EF, as measured by antisaccade eye-movement performance.

METHODS

Patients were tested at baseline (before olanzapine), 3-5 days post-medication, and 12-14 days post-medication. Patients were also assessed on the Positive and Negative Syndrome Scale (PANSS) to measure the severity of schizophrenia-related symptoms, and administered the Stroop task, a test of EF. Nine matched controls were also tested on the antisaccade and Stroop.

RESULTS

Both groups showed improvement on Stroop and antisaccade; however, the schizophrenia group improved significantly more on antisaccade, indicating an additional benefit of olanzapine on EF performance. Patients with poorer baseline antisaccade performance (High-Deficit) showed significantly greater improvement on the antisaccade task than patients with better baseline performance (Low-Deficit), suggesting that baseline EF impairment predicts the magnitude of cognitive improvement with olanzapine. These subgroups showed significant and equivalent improvement on PANSS scores, indicating that improvement on the antisaccade task with olanzapine was not a result of differences in magnitude of clinical improvement.

CONCLUSIONS

This preliminary study provides evidence that olanzapine may be most advantageous for patients with greater baseline EF deficits.

Characterizing Anterior Segment OCT Angle Landmarks of the Trabecular Meshwork Complex

PURPOSE

To identify the presence or absence of 3 identifiable landmarks: trabecular meshwork (TM), Schlemm's canal (SC), and a novel landmark termed the band of extracanalicular limbal lamina (BELL), which is a landmark adjacent to SC visible on anterior segment (AS) OCT. These landmarks also were analyzed pathologically to identify all 3 landmarks.

DESIGN

Retrospective review.

PARTICIPANTS

One eye per participant from prior institutional review board-approved studies in which AS OCT imaging was performed.

METHODS

Horizontal images from 2-dimensional angle analysis scans using a CASIA SS-1000 (Tomey, Nagoya, Japan) AS OCT were evaluated by masked readers. Logistic regression was used to analyze the potential factors of age, gender, race, intraocular pressure, gonioscopy grade, angle location, and history or presence of surgery on the visibility of these structures. Pathologic correlation on 5 previously enucleated eyes also was performed.

MAIN OUTCOME MEASURES

Presence or absence of angle landmarks-TM, SC, and BELL-using Anterior Chamber Analysis and Interpretation software (ACAI, Houston, TX).

RESULTS

Three hundred three angles of 153 horizontal images were included in this study. The mean age was 51.5±16.0 years, with 98 women (64%) and 100 white persons (66%). The outer border of the BELL was observed in 288 angles (95%), TM was found in 220 angles (73%), and SC was seen in 120 angles (40%). The outer border of the BELL was more visible in white persons (P = 0.02) than Asians and in eyes with a Spaeth gonioscopy grade of E than those with a grade of A (P = 0.02). Both TM (P = 0.001) and SC (P = 0.001) were more visible in temporal angles (81% for TM, 49% for SC) than in nasal angles (64% for TM, 30% for SC). Additionally, SC was more visible in open angles (43%) than in narrow angles (27%; P = 0.02). These 3 structures were verified in a pathologic study.

CONCLUSIONS

We identified a novel AS OCT landmark adjacent to SC. This structure also was identified on pathologic samples from enucleated eyes. Further study is needed to determine the pathophysiologic relevance of these findings.

Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology

OBJECTIVE

The objective was to evaluate the sensitivity and specificity of computed tomography (CT) diagnosis of open globes, determine which imaging factors are most predictive of open globe injuries, and evaluate the agreement between neuroradiologist and ophthalmologist readers for diagnosis of open and closed globes.

METHODS

This study was a retrospective cohort study. Patients who presented to Memorial Hermann-Texas Medical Center with suspicion for open globes were reviewed. One neuroradiologist and two ophthalmologists masked to clinical information reviewed CT images for signs concerning for open globe including change in globe contour, anterior chamber deformation, intraocular air, vitreous hemorrhage, subretinal fluid indicating retinal or choroidal detachment, dislocated or absent lens, intraocular foreign body, and orbital fracture. Using the clinically or surgically confirmed globe status as the true globe status, sensitivity, specificity, and agreement (kappa) were calculated and used to investigate which imaging factors are most predictive of open globe injuries.

RESULTS

A total of 114 patients were included: 35 patients with open globes and 79 patients with closed globes. Specificity was greater than 97% for each reader, and sensitivity ranged from 51% to 77% among readers. The imaging characteristics most consistently used to predict an open globe injury were change in globe contour and vitreous hemorrhage (sensitivity = 43% to 57%, specificity > 98%). The agreement of impression of open globe between the neuroradiologist and ophthalmologists was good and excellent between ophthalmologists.

CONCLUSIONS

Computed tomography imaging is not absolute, and the sensitivity is still inadequate to be fully relied upon. The CT imaging findings most predictive of an open globe injury were change in globe contour and vitreous hemorrhage. Clinical examination or surgical exploration remains the most important component in evaluating for a suspected open globe, with CT imaging as an adjunct.

Slowed Prosaccades and Increased Antisaccade Errors As a Potential Behavioral Biomarker of Multiple System Atrophy

Current clinical diagnostic tools are limited in their ability to accurately differentiate idiopathic Parkinson’s disease (PD) from multiple system atrophy (MSA) and other parkinsonian disorders early in the disease course, but eye movements may stand as objective and sensitive markers of disease differentiation and progression. To assess the use of eye movement performance for uniquely characterizing PD and MSA, subjects diagnosed with PD (N = 21), MSA (N = 11), and age-matched controls (C, N = 20) were tested on the prosaccade and antisaccade tasks using an infrared eye tracker. Twenty of these subjects were retested ~7 months later. Saccade latencies, error rates, and longitudinal changes in saccade latencies were measured. Both PD and MSA patients had greater antisaccade error rates than C subjects, but MSA patients exhibited longer prosaccade latencies than both PD and C patients. With repeated testing, antisaccade latencies improved over time, with benefits in C and PD but not MSA patients. In the prosaccade task, the normal latencies of the PD group show that basic sensorimotor oculomotor function remain intact in mid-stage PD, whereas the impaired latencies of the MSA group suggest additional degeneration earlier in the disease course. Changes in antisaccade latency appeared most sensitive to differences between MSA and PD across short time intervals. Therefore, in these mid-stage patients, increased antisaccade errors combined with slowed prosaccade latencies might serve as a useful marker for early differentiation between PD and MSA, and, antisaccade performance, a measure of MSA progression. Together, our findings suggest that eye movements are promising biomarkers for early differentiation and progression of parkinsonian disorders.

Impaired Cognitive Performance in Youth Athletes Exposed to Repetitive Head Impacts

Worldwide, more than 22 million children and adolescents are exposed to repetitive head impacts (RHI) in soccer. Evidence indicates cumulative effects on brain structure, but it is not known whether exposure to RHI affects cognitive improvement in adolescents. The aim of the study was to determine whether exposure to RHI while heading the ball in soccer affects improvement in cognitive performance in adolescents over time. The study group consisted of a convenience sample of 16 male soccer players (mean age 15.7 ± 0.7 years). A comparison cohort of 14 male non-contact sports athletes (mean age 14.9 ± 1.1 years) was recruited from competitive athletic clubs and group-matched in age. Using the ProPoint and AntiPoint tasks, sensorimotor and cognitive functions were measured over both immediate (pre- vs. post-training) as well as across multiple time points within a play season. The number and type of head impacts that occurred during the training were counted. The main outcome measure was the change in response time (RT) in the ProPoint and AntiPoint tasks. The immediate (pre- vs. post-training) and longer-term (across a play season) change in RT was analyzed, and the effect of the number and type of head impacts was tested. Thirty athletes with and without exposure to RHI demonstrated a decrease in RT in both tasks immediately after training. Over the play season, both groups showed improvement in sensorimotor function. While the control group also improved in cognitive performance, the soccer players did not, however. Further, the more long headers performed, the slower the improvement in RT over the season. Youth athletes experience an immediate cognitive improvement after training most likely because of physical exercise. Results of this study also suggest an association between exposure to specific RHI (long headers) and lack of improvement in cognitive performance in youth athletes over time.

Wide-field diffuse amacrine cells in the monkey retina contain immunoreactive Cocaine- and Amphetamine-Regulated Transcript (CART)

The goals of this study were to localize the neuropeptide Cocaine- and Amphetamine-Regulated Transcript (CART) in primate retinas and to describe the morphology, neurotransmitter content and synaptic connections of the neurons that contain it. Using in situ hybridization, light and electron microscopic immunolabeling, CART was localized to GABAergic amacrine cells in baboon retinas. The CART-positive cells had thin, varicose dendrites that gradually descended through the inner plexiform layer and ramified extensively in the innermost stratum. They resembled two types of wide-field diffuse amacrine cells that had been described previously in macaque retinas using the Golgi method and also A17, serotonin-accumulating and waterfall cells of other mammals. The CART-positive cells received synapses from rod bipolar cell axons and made synapses onto the axons in a reciprocal configuration. The CART-positive cells also received synapses from other amacrine cells. Some of these were located on their primary dendrites, and the presynaptic cells there included dopaminergic amacrine cells. Although some CART-positive somas were localized in the ganglion cell layer, they did not contain the ganglion cell marker RNA binding protein with multiple splicing (RBPMS). Based on these results and electrophysiological studies in other mammals, the CART-positive amacrine cells would be expected to play a major role in the primary rod pathway of primates, providing feedback inhibition to rod bipolar cells.

Comparing Laser Peripheral Iridotomy to Cataract Extraction in Narrow Angle Eyes Using Anterior Segment Optical Coherence Tomography

Purpose

To evaluate the changes in anterior chamber angle (ACA) parameters in primary angle closure (PAC) spectrum eyes before and after cataract extraction (CE) and compare to the changes after laser peripheral iridotomy (LPI) using anterior segment optical coherence tomography (ASOCT).

Methods

Twenty-eight PAC spectrum eyes of 18 participants who underwent CE and 34 PAC spectrum eyes of 21 participants who underwent LPI were included. ASOCT images with 3-dimensional mode angle analysis scans were taken with the CASIA SS-1000 (Tomey Corp., Nagoya, Japan) before and after CE or LPI. Mixed-effect model analysis was used to 1) compare best-corrected visual acuity, intraocular pressure, and ACA parameters before and after CE; 2) identify and estimate the effects of potential contributing factors affecting changes in ACA parameters; and 3) compare CE and LPI treatment groups.

Results

The increase in average angle parameters (TISA750 and TICV750) was significantly greater after CE than LPI. TICV750 increased by 102% (2.114 [±1.203] μL) after LPI and by 174% (4.546 [± 1.582] μL) after CE (P < 0.001). Change of TICV750 in the CE group was significantly affected by age (P = 0.002), race (P = 0.006), and intraocular lens power (P = 0.037).

Conclusions

CE results in greater anatomic changes in the ACA than LPI in PAC spectrum eyes. ASOCT may be used to follow anatomic changes in the angle after intervention.

Determination and Validation of Thresholds of Anterior Chamber Parameters by Dedicated Anterior Segment Optical Coherence Tomography

PURPOSE

To determine and validate thresholds of anterior chamber angle (ACA) parameters in discriminating open- vs narrow-angle eyes using images from dedicated anterior segment optical coherence tomography (DASOCT).

DESIGN

Reliability analysis.

METHODS

Eyes imaged by DASOCT and examined with gonioscopy were reviewed. By gonioscopy, eyes were classified as narrow if posterior trabecular meshwork was not visible and open if the angle was open to scleral spur and beyond. Imaging was performed in the dark with the CASIA SS-1000 (Tomey, Nagoya, Japan). ACA parameters angle opening distance (AOD), trabecular-iris space area (TISA), trabecular-iris circumference volume (TICV), length of iridotrabecular contact (ITC), and extent and area of ITC were calculated. AOD, TISA, and TICV were measured at both 500 μm and 750 μm from the scleral spur landmark. Study eyes were randomly divided into training and testing sets. Thresholds were calculated from the training set. Sensitivity, specificity, and agreement were then calculated against the clinical classification using the testing set.

RESULTS

One hundred and eighty-nine eyes (111 open, 78 narrow, including 8 borderline angles) were included. Using the threshold determined in the training set on the testing set, 9 of 24 ACA parameters had no misclassification of narrow-angle eyes as open (sensitivity = 1.0). Of 9 parameters, the specificity was >0.79. The highest kappa values (kappa = 0.91) was AOD750 inferiorly at 0.31 mm threshold, followed by both TICV500 at 1.92 μL and TICV750 at 4.00 μL with kappa = 0.86.

CONCLUSION

The parameters with the best discriminative ability for detecting narrow angles were AOD750 inferiorly, TICV500, and TICV750.

Establishing Age-Adjusted Reference Ranges for Iris-Related Parameters in Open Angle Eyes with Anterior Segment Optical Coherence Tomography

Purpose

Define criteria for iris-related parameters in an adult open angle population as measured with swept source Fourier domain anterior segment optical coherence tomography (ASOCT).

Methods

Ninety-eight eyes of 98 participants with open angles were included and stratified into 5 age groups (18–35, 36–45, 46–55, 56–65, and 66–79 years). ASOCT scans with 3D mode angle analysis were taken with the CASIA SS-1000 (Tomey Corporation, Nagoya, Japan) and analyzed using the Anterior Chamber Analysis and Interpretation software. Anterior iris surface length (AISL), length of scleral spur landmark (SSL) to pupillary margin (SSL-to-PM), iris contour ratio (ICR = AISL/SSL-to-PM), pupil radius, radius of iris centroid (RICe), and iris volume were measured. Outcome variables were summarized for all eyes and age groups, and mean values among age groups were compared using one-way analysis of variance. Stepwise regression analysis was used to investigate demographic and ocular characteristic factors that affected each iris-related parameter.

Results

Mean (±SD) values were 2.24 mm (±0.46), 4.06 mm (±0.27), 3.65 mm (±0.48), 4.16 mm (±0.47), 1.14 (±0.04), 1.51 mm² (±0.23), and 38.42 μL (±4.91) for pupillary radius, RICe, SSL-to-PM, AISL, ICR, iris cross-sectional area, and iris volume, respectively. Both pupillary radius (P = 0.002) and RICe (P = 0.027) decreased with age, while SSL-to-PM (P = 0.002) and AISL increased with age (P = 0.001). ICR (P = 0.54) and iris volume (P = 0.49) were not affected by age.

Conclusion

This study establishes reference values for iris-related parameters in an adult open angle population, which will be useful for future studies examining the role of iris changes in pathologic states.

Intact Reflexive but Deficient Voluntary Social Orienting in Autism Spectrum Disorder

Impairment in social interactions is a primary characteristic of people diagnosed with autism spectrum disorder (ASD). Although these individuals tend to orient less to naturalistic social cues than do typically developing (TD) individuals, laboratory experiments testing social orienting in ASD have been inconclusive, possibly because of a failure to fully isolate reflexive (stimulus-driven) and voluntary (goal-directed) social orienting processes. The purpose of the present study was to separately examine potential reflexive and/or voluntary social orienting differences in individuals with ASD relative to TD controls. Subjects (ages 7–14) with high-functioning ASD and a matched control group completed three gaze cueing tasks on an iPad in which individuals briefly saw a face with averted gaze followed by a target after a variable delay. Two tasks were 100% predictive with either all congruent (target appears in gaze direction) or all incongruent (target appears opposite from gaze direction) trials, respectively. Another task was non-predictive with these same trials (half congruent and half incongruent) intermixed randomly. Response times (RTs) to the target were used to calculate reflexive (incongruent condition RT—congruent condition RT) and voluntary (non-predictive condition RT—predictive condition RT) gaze cueing effects. Subjects also completed two additional non-social orienting tasks (ProPoint and AntiPoint). Subjects with ASD demonstrate intact reflexive but deficient voluntary gaze following. Similar results were found in a separate test of non-social orienting. This suggests problems with using social cues, but only in a goal-directed fashion, in our sample of high-functioning individuals with ASD. Such findings may not only explain inconclusive previous findings but more importantly be critical for understanding social dysfunctions in ASD and for developing future interventions.

Detection of Subtle Cognitive Changes after mTBI Using a Novel Tablet-Based Task

This study examined the potential for novel tablet-based tasks, modeled after eye tracking techniques, to detect subtle sensorimotor and cognitive deficits after mild traumatic brain injury (mTBI). Specifically, we examined whether performance on these tablet-based tasks (Pro-point and Anti-point) was able to correctly categorize concussed versus non-concussed participants, compared with performance on other standardized tests for concussion. Patients admitted to the emergency department with mTBI were tested on the Pro-point and Anti-point tasks, a current standard cognitive screening test (i.e., the Standard Assessment of Concussion [SAC]), and another eye movement-based tablet test, the King-Devick(®) (KD). Within hours after injury, mTBI patients showed significant slowing in response times, compared with both orthopedic and age-matched control groups, in the Pro-point task, demonstrating deficits in sensorimotor function. Mild TBI patients also showed significant slowing, compared with both control groups, on the Anti-point task, even when controlling for sensorimotor slowing, indicating deficits in cognitive function. Performance on the SAC test revealed similar deficits of cognitive function in the mTBI group, compared with the age-matched control group; however, the KD test showed no evidence of cognitive slowing in mTBI patients, compared with either control group. Further, measuring the sensitivity and specificity of these tasks to accurately predict mTBI with receiver operating characteristic analysis indicated that the Anti-point and Pro-point tasks reached excellent levels of accuracy and fared better than current standardized tools for assessment of concussion. Our findings suggest that these rapid tablet-based tasks are able to reliably detect and measure functional impairment in cognitive and sensorimotor control within hours after mTBI. These tasks may provide a more sensitive diagnostic measure for functional deficits that could prove key to earlier detection of concussion, evaluation of interventions, or even prediction of persistent symptoms.

Optimal number of angle images for calculating anterior angle volume and iris volume measurements

PURPOSE

We determined the optimal number of angle images required to obtain reliable measurements of trabecular-iris circumferential volume (TICV) and iris volume (IV) using swept-source Fourier domain anterior segment optical coherence tomography (SSFD-ASOCT) scans in narrow angle eyes.

METHODS

Scleral spur landmarks (SSL) were manually identified on ASOCT angle images from 128 meridians from each of 24 eyes with chronic primary angle closure (PAC) spectrum of disease. The anterior and posterior corneal curves, and the anterior and posterior iris surfaces were identified automatically by the anterior chamber analysis and interpretation (ACAI) software, then manually examined and edited by the reader if required. Trabecular-iris circumferential volume at 750 μm from SSL (TICV750) and IV were subsequently calculated using varying numbers of angle images. Threshold error was determined to be less than the lower 95% confidence limit of mean absolute percent error (MAPE) of the change in TICV or IV resulting from laser peripheral iridotomy, which would be 17% for TICV and 5% for IV, based on previous studies. The optimal number of angle images was the smallest number of images where MAPE was less than this threshold for TICV and IV.

RESULTS

A total of 32 equally-spaced angle images (16 meridians) was required to estimate TICV750 and 16 angle images (8 meridians) to estimate IV. Both were within 4.6% and 1.6% of MAPE, respectively.

CONCLUSIONS

It is possible to determine TICV and IV parameters reliably in narrow angles without evaluating all 128 meridians obtained with SSFD-ASOCT.

Outcomes of a rotational dissection system in gross anatomy

At the University of Texas Houston Medical School, a rotational dissection system was introduced to improve coordination between the Gross Anatomy and the Introduction to Clinical Medicine (ICM) courses. Six students were assigned to each cadaver and divided into two teams. For each laboratory, one team was assigned to dissect and the other to attend ICM or study independently. For the next laboratory, the assignments were reversed. At the start of the session, the team that had dissected previously spent 30 minutes teaching the other team. In 2012, the students were given three traditional practical examinations with 50 questions drawn equally from each laboratory. Students also completed three mid-course evaluations. There were no significant differences in overall performance between the two teams. Nevertheless, we wanted to determine how well individual students identified structures they had dissected compared with those they had not. For dissected structures, the mean percent correct was 80.0 ± 13.0 (mean ± standard deviation), and for undissected structures, it was 78.3 ± 14.1. The difference was small, but statistically significant (P = 0.0007). Although this result validated the concerns expressed by some students, it did not appear that a change in the system was justified. Students were generally enthusiastic about the opportunity to learn clinical skills in the first semester of medical school, and 91-96% of the students agreed that learning anatomy at the same time helped them understand the physical examination exercises in ICM.

Risk factors associated with retinal hemorrhage in suspected abusive head trauma

PURPOSE

To determine risk factors associated with retinal hemorrhage (RH) in pediatric abusive head trauma (AHT) suspects.

METHODS

Records of children aged 0-3 years hospitalized for suspected AHT from January 2007 to November 2011 were retrospectively reviewed in this case-control study. Children were classified into case and control groups based on RH presence. Medical history, presenting symptoms, reasons, and characteristics of injury were recorded. Logistic regression analysis was performed to identify risk factors.

RESULTS

A total of 168 children (104 males) were included. Of these, 103 were classified as cases and 65 as controls. The mean age (with standard deviation) was 9.3 ± 8.3 months (range, 1 day-36 months). Of the 103 cases, 22 (21%) had subretinal hemorrhage, 9 (9%) had retinoschisis, and 1 (1%) had vitreous hemorrhage. Children presenting with lethargy or altered mental status (P < 0.0001), subdural hemorrhage (P < 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P = 0.01546) were likely to have RH. All 23 children with skull or nonskull fracture without intracranial hemorrhage did not have RH (P < 0.0001 both categories).

CONCLUSIONS

Retinal hemorrhages were almost never found in the absence of intracranial hemorrhage and not found in the setting of fracture without intracranial hemorrhage.

The significance of minimal adjustments in the Muller's muscle and conjunctiva resection procedure to achieve the phenylephrine result

PURPOSE

To determine if adjusting the resection amount within a small range has a significant effect in the amount of lift achieved when performing the Muller's muscle and conjunctiva resection procedure (MMCR).

METHODS

A retrospective chart review was performed analyzing 102 eyelids of 68 patients with involutional blepharoptosis that had a MMCR resection amount ranging from 8.0-9.5 mm performed by a single surgeon (P.S.)

RESULTS

The average lift for all resections was 2.30 mm. When comparing amongst all resection groups, there was no significant difference in the amount of lift obtained (p = 0.2454).

CONCLUSION

When performing the MMCR procedure, adjusting the resection amount within a small range of 8.0-9.5 mm does not affect the amount of lift achieved.

Rod electrical coupling is controlled by a circadian clock and dopamine in mouse retina

Rod single-photon responses are critical for vision in dim light. Electrical coupling via gap junction channels shapes the light response properties of vertebrate photoreceptors, but the regulation of rod coupling and its impact on the single-photon response have remained unclear. To directly address these questions, we developed a perforated patch-clamp recording technique and recorded from single rod inner segments in isolated intact neural mouse retinae, maintained by superfusion. Experiments were conducted at different times of the day or under constant environmental conditions, at different times across the circadian cycle. We show that rod electrical coupling is regulated by a circadian clock and dopamine, so that coupling is weak during the day and strong at night. Altogether, patch-clamp recordings of single-photon responses in mouse rods, tracer coupling, receptive field measurements and pharmacological manipulations of gap junction and dopamine receptor activity provide compelling evidence that rod coupling is modulated in a circadian manner. These data are consistent with computer modelling. At night, single-photon responses are smaller due to coupling, but the signal-to-noise ratio for a dim (multiphoton) light response is increased at night because of signal averaging between coupled rods.

Oculomotor executive function abnormalities with increased tic severity in Tourette syndrome

BACKGROUND

Reports conflict as to whether Tourette syndrome (TS) confers deficits in executive function. This study's aim was to evaluate executive function in youths with TS using oculomotor tasks while controlling for confounds of tic severity, age, medication, and severity of comorbid disorders.

METHOD

Four saccade tasks requiring the executive functions of response generation, response inhibition, and working memory (prosaccade, antisaccade, 0-back, and 1-back) were administered. Twenty youths with TS and low tic severity (TS-low), nineteen with TS and moderate tic severity (TS-moderate), and 29 typically developing control subjects (Controls) completed the oculomotor tasks.

RESULTS

There were small differences across groups in the prosaccade task. Controlling for any small sensorimotor differences, TS-moderate subjects had significantly higher error rates than Controls and TS-low subjects in the 0-back and 1-back tasks. In the 1-back task, these patients also took longer to respond than Controls or TS-low subjects.

CONCLUSIONS

In a highly controlled design, the findings demonstrate for the first time that increased tic severity in TS is associated with impaired response inhibition and impaired working memory and that these executive function deficits cannot be accounted for by differences in age, medication or comorbid symptom severity.

Refractive outcomes following bevacizumab monotherapy compared with conventional laser treatment: a randomized clinical trial

IMPORTANCE

Children born prematurely who develop retinopathy of prematurity (ROP) often develop myopia, and those who require laser treatment may develop very high myopia, which has considerable clinical consequences.

OBJECTIVE

To report refractive outcomes in preterm infants who developed ROP in zone I or zone II posterior as stage 3+ ROP or aggressive posterior ROP (APROP).

DESIGN, SETTING, AND PARTICIPANTS

All infants received intravitreal bevacizumab or laser therapy in a prospective, stratified, randomized, controlled, masked, multicenter clinical trial, Bevacizumab Eliminates the Angiogenic Threat for ROP (BEAT-ROP). Children who received intravitreal bevacizumab or laser in the BEAT-ROP clinical trial, with treatment randomized by infant, underwent cycloplegic retinoscopic refraction at a mean age of 2½ years. Fifteen centers with both pediatric and vitreoretinal ophthalmologists participating in level 3 neonatal intensive care units in academic centers with institutional review board approval were included in the trial. Of the originally enrolled 150 infants (300 eyes) in the BEAT-ROP clinical trial, 13 infants (26 eyes) died (6 received intravitreal bevacizumab; 7 received laser) and 19 eyes had intraocular surgery (6 infants bilaterally). Thus, 45 eyes (19 infants bilaterally) were excluded, leaving 131 infants (255 eyes, including 21 eyes that received a successful second treatment for recurrence).

INTERVENTIONS

Follow-up of the BEAT-ROP cohort.

MAIN OUTCOMES AND MEASURES

Spherical equivalent refractive outcomes and their distribution by ROP zone and treatment.

RESULTS

Refractions were available for 109 of 131 eligible infants (83.2%) and 211 of 255 eyes (82.7%). Mean (SD) spherical equivalent refractions were as follows: zone I, -1.51 (3.42) diopters (D) in 52 eyes that received intravitreal bevacizumab and -8.44 (7.57) D in 35 eyes that received laser treatment (P < .001); and zone II posterior, -0.58 (2.53) D in 58 eyes that received intravitreal bevacizumab and -5.83 (5.87) D in 66 eyes that received laser treatment (P < .001). Very high myopia (≥-8.00 D) occurred in zone I in 2 of 52 (3.8%) eyes that received intravitreal bevacizumab and in 18 of 35 (51.4%) eyes that received laser treatment (P < .001). Very high myopia occurred in zone II posterior in 1 of 58 (1.7%) eyes that received intravitreal bevacizumab and in 24 of 66 (36.4%) eyes that received laser treatment (P < .001).

CONCLUSIONS AND RELEVANCE

More very high myopia was found in eyes that received laser treatment than in eyes that received intravitreal bevacizumab. This difference is possibly related to anterior segment development that is present with intravitreal bevacizumab but minimal or absent following laser treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00622726.

Efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity

BACKGROUND

Retinopathy of prematurity is a leading cause of childhood blindness worldwide. Peripheral retinal ablation with conventional (confluent) laser therapy is destructive, causes complications, and does not prevent all vision loss, especially in cases of retinopathy of prematurity affecting zone I of the eye. Case series in which patients were treated with vascular endothelial growth factor inhibitors suggest that these agents may be useful in treating retinopathy of prematurity.

METHODS

We conducted a prospective, controlled, randomized, stratified, multicenter trial to assess intravitreal bevacizumab monotherapy for zone I or zone II posterior stage 3+ (i.e., stage 3 with plus disease) retinopathy of prematurity. Infants were randomly assigned to receive intravitreal bevacizumab (0.625 mg in 0.025 ml of solution) or conventional laser therapy, bilaterally. The primary ocular outcome was recurrence of retinopathy of prematurity in one or both eyes requiring retreatment before 54 weeks' postmenstrual age.

RESULTS

We enrolled 150 infants (total sample of 300 eyes); 143 infants survived to 54 weeks' postmenstrual age, and the 7 infants who died were not included in the primary-outcome analyses. Retinopathy of prematurity recurred in 4 infants in the bevacizumab group (6 of 140 eyes [4%]) and 19 infants in the laser-therapy group (32 of 146 eyes [22%], P=0.002). A significant treatment effect was found for zone I retinopathy of prematurity (P=0.003) but not for zone II disease (P=0.27).

CONCLUSIONS

Intravitreal bevacizumab monotherapy, as compared with conventional laser therapy, in infants with stage 3+ retinopathy of prematurity showed a significant benefit for zone I but not zone II disease. Development of peripheral retinal vessels continued after treatment with intravitreal bevacizumab, but conventional laser therapy led to permanent destruction of the peripheral retina. This trial was too small to assess safety. (Funded by Research to Prevent Blindness and others; ClinicalTrials.gov number, NCT00622726.).

Association of dyslipidemia in moderate to severe meibomian gland dysfunction

PURPOSE

To determine whether meibomian gland disease, a major contributor to dry eye syndrome, is associated with dyslipidemia.

DESIGN

Retrospective case-control study.

METHODS

setting: Clinical practice. patient or study population: Sixty-six patients from January 2008 to July 2009 with moderate to severe meibomian gland disease whose serum lipid levels were obtained. We excluded patients who were already taking lipid-altering substances and patients with rheumatologic disease. We analyzed several parameters in prevalence of dyslipidemia (total cholesterol > 200 mg/dL, low-density lipoprotein [LDL] > 130 mg/dL, high-density lipoprotein [HDL] < 40 mg/dL, and triglycerides >150 mg/dL) in MGD patients and compared these patients to the general population as reported by data from the National Health and Nutrition Examination Survey (NHANES). main outcome measure: The prevalence of dyslipidemia (elevated total cholesterol, elevated LDL, decreased HDL, or elevated triglycerides) in patients with moderate to severe MGD.

RESULTS

Patients with moderate to severe MGD had a higher incidence of dyslipidemia with respect to elevated total cholesterol (>200 mg/dL), 67.4% to 45.1% (P = .0012) when compared to population controls. There was a smaller number of MGD patients with low HDL (HDL < 40 mg/dL), 6.5%, when compared to controls, 15.7% (P = .045). The incidence of increased LDL was not statistically significant (P = .184). There was a statistically smaller number of MGD patients with high triglycerides (TG > 150 mg/dL), 15.2%, when compared to controls, 33.1% (P = .0049).

CONCLUSIONS

Patients with moderate to severe MGD have a higher incidence of dyslipidemia with respect to elevated total cholesterol than the general population. Surprisingly, the component of total cholesterol that contributed most to this increase in total cholesterol came from elevated serum HDL levels. To our knowledge, elevated HDL has not been associated with any pathologic state. Patients with MGD had a statistically significant lower incidence of hypoalphalipoproteinemia (low HDL) than the general population. Patients with MGD also had a lower incidence of hypertriglyceridemia than the general population.

Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy

BACKGROUND

There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia.

METHODS/MATERIALS

Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1-6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

RESULTS

The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04).

CONCLUSIONS

Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

Caffeine in children with obstructive sleep apnea

BACKGROUND

Children with obstructive sleep apnea (OSA) have a higher rate of adverse post-extubation respiratory events, such as laryngospasm, upper airway obstruction, apnea, desaturation and/or need for re-intubation. They are overly sensitive to sedatives and narcotics. Although the etiology of OSA is primarily obstruction (mechanical or neuromuscular), a central element may contribute to OSA. Caffeine citrate has been shown to be effective in treating apnea of prematurity. This study evaluated whether the administration of caffeine benzoate to children with OSA decreases the number of children who experience adverse post-extubation respiratory events.

METHODS

In a randomized, double-blind and placebo-controlled study, children with OSA scheduled for adenotonsillectomy (T&A) received either caffeine benzoate, 20 mg/kg IV, (caffeine group, n = 36) or saline (placebo group, n = 36). The primary outcome evaluated the number of children who developed adverse post-extubation respiratory events, and the secondary outcome was the incidence of those events.

RESULTS

The results demonstrated the two groups differed in the number of children who developed adverse post-extubation respiratory events (p = 0.032). The overall incidence of adverse postoperative respiratory events was less in the caffeine group than the placebo group (p = 0.0196).

CONCLUSION

In children with OSA scheduled for T&A, administration of caffeine benzoate, 20 mg/kg IV, decreased the number of children who developed adverse post-extubation respiratory events and decreased the overall incidence of adverse post-extubation respiratory events. PACU duration, hospital discharge time and postoperative delirium did not differ between groups.

Comparison of the Ocular Hypotensive Efficacy of Adjunctive Brimonidine 0.15% or Brinzolamide 1% in Combination with Travoprost 0.004%

PURPOSE

To compare efficacies of adjunctive therapy with brimonidine 0.15% and adjunctive therapy with brinzolamide 1% in combination with travoprost 0.004%.

DESIGN

Three-month randomized, parallel-group, double-masked, multicenter clinical trial.

PARTICIPANTS

Patients with primary open-angle glaucoma, exfoliation glaucoma, or ocular hypertension with intraocular pressure (IOP) > 18 mmHg on monotherapy with travoprost (N = 163).

METHODS

Patients were randomized to receive adjunctive therapy with twice-daily brimonidine (N = 79) or twice-daily brinzolamide (N = 84). Treatment efficacy was assessed after 1 and 3 months of combination therapy. Intraocular pressure was measured at 8 am, noon, and 4 pm at baseline (on travoprost monotherapy) and after 3 months of combination therapy. Mean diurnal IOP was defined as the average of the IOP measurements at these 3 time points. Adverse events were recorded at each visit.

MAIN OUTCOME MEASURE

Difference between treatment groups in mean diurnal IOP at month 3, adjusted for difference in baseline IOP, using analysis of covariance.

RESULTS

Mean diurnal IOPs (+/- standard error of the mean) at baseline were 21.7+/-0.33 mmHg in the brimonidine group and 21.1+/-0.29 mmHg in the brinzolamide group (P = 0.16). Mean diurnal IOPs at month 3 were 19.6+/-0.41 mmHg in the brimonidine group and 18.4+/-0.33 mm Hg in the brinzolamide group (P = 0.019). At month 3, mean diurnal IOPs, adjusted for difference in baseline IOP, were 19.3+/-0.27 in the brimonidine group and 18.6+/-0.25 in the brinzolamide group (P = 0.035).

CONCLUSIONS

The combination of travoprost and brinzolamide was statistically significantly more efficacious than the combination of travoprost and brimonidine in lowering IOP. The clinical significance of this difference is uncertain.

Presurgical caudal block attenuates stress response in children

BACKGROUND

Our aim was to determine if the anesthesia technique for pain relief in children affects the stress response after minor surgery. A rise in blood glucose reflects stress-related effects in children who do not receive glucose perioperatively.

METHODS

Twenty-eight children, ages 17-81 mos, undergoing elective urologic procedures, were enrolled. For pain relief, patients received presurgical caudal block (group 1), intravenous narcotics (group 2), or postsurgical caudal block (group 3). Blood samples were analyzed for glucose concentrations immediately after induction of anesthesia at baseline, 15 min after surgical incision (second sample), and 30 min after end of surgery (third sample).

RESULTS

In group 1 there was no change in glucose concentration in the second or third samples compared to baseline, while in group 3 there were significant increases in those samples, and in group 2 there was a significant increase in the second sample compared to baseline. Children in group 1 required significantly fewer narcotics in the postanesthesia care unit (PACU), and those in group 2 had significantly longer PACU and hospital durations.

CONCLUSIONS

Presurgical caudal analgesia attenuates the stress response of anesthesia and surgery and decreases postoperative narcotic use while narcotics prolong PACU and discharge times.

Regional analgesia combined with avoidance of narcotics may reduce the incidence of postoperative vomiting in children

BACKGROUND

The anesthesia literature cites a high incidence of postoperative vomiting (POV) after pediatric ochidopexy and hernia repair (34-50%) and after penile procedures (37-49%). We hypothesized that regional analgesia combined with avoidance of narcotics administered to children scheduled for lower abdominal or urologic procedures may be associated with a lower incidence of POV. The aim of this prospective study was to 1) assess the incidence of POV in children in the hospital and during a 24-h post-anesthesia study period, and 2) evaluate the effect of age on POV.

METHODS

After obtaining institutional and parental consent, 110 pediatric outpatients, 1-12 yr old, ASA physical status I or II, scheduled for elective outpatient urologic or lower abdominal procedures, were enrolled. Children were fasting and premedicated with midazolam, 0.5 mg/kg p.o. They received a combined light general anesthesia and a presurgical caudal block. Anesthesia was induced via a mask and consisted of halothane and nitrous oxide in oxygen. For the caudal block 1 ml/kg of 0.25% bupivacaine or 0.2% ropivacaine were used to provide intra- and postoperative pain relief. No prophylactic antiemetics were administered.

RESULTS

All caudal blocks provided adequate intraoperative pain relief. The incidence of POV was low, 12% at the hospital, 13% for the 24-h study period, and was not affected by age.

CONCLUSIONS

We concluded that regional analgesia combined with the avoidance of narcotics administered to children scheduled for elective urologic or lower abdominal procedures, is associated with a lower incidence of POV and that age did not affect the incidence of POV.

Prediction of Corneal Haze Using an Ablation Depth/Corneal Thickness Ratio After Laser Epithelial Keratomileusis

PURPOSE

To investigate the usefulness of ablation depth/corneal thickness (AD/CT) ratio to predict corneal haze after laser epithelial keratomileusis (LASEK) using a retrospective, comparative, interventional case series.

METHODS

Fifty patients (90 eyes; mean age 40.9 years) with myopia, hyperopia, and/or astigmatism underwent bilateral or unilateral LASEK for correction of refractive error. After epithelial flaps were created using an 18% alcohol solution, bilateral or unilateral LASEK was performed using the Alcon Autonomous LADARVision 4000 excimer laser. Visual acuity (best spectacle-corrected and uncorrected) and refractive error were measured before and after LASEK. Corneas were assessed by two independent evaluators under a slit-lamp biomicroscope with broad tangential illumination. The relative haze scale was quantitated: 0 (clear), 0.5+ (trace), 1+ (mild), 2+ (moderate), 3+ (marked), and 4+ (severe).

RESULTS

Mean preoperative spherical equivalent refraction was -5.46 +/- 3.74 D (range -12.375 to +5.00 D), mean ablation depth was 93.04 +/- 45.03 microm (range 21.2 to 207.2 microm), and mean AD/CT ratio was 0.18 +/- 0.09 (range 0.04 to 0.41). Of 90 eyes, 40 eyes had a higher ablation depth (AD/CT ratio > 0.18) and 50 eyes had a lower ablation depth (AD/CT ratio < 0.18); 92.5% of eyes in the higher ratio group developed clinically significant haze (1+ or greater). In the lower ratio group, 94% of eyes developed no more than 1+ corneal haze, if any.

CONCLUSION

The ablation depth/corneal thickness ratio is useful for predicting corneal haze after LASEK. An AD/CT ratio of 0.18 or more suggests that patients have a high risk of developing clinically significant haze (1+ or more) after LASEK.

Evaluating the Texas Statewide Family Practice Preceptorship Program, 1992-2000

PURPOSE

Since 1979, the Texas Statewide Family Practice Preceptorship Program (TSFPPP) has conducted ambulatory preceptorships to increase the number of medical students selecting family practice residencies. The authors describe the evaluation of the TSFPPP's efficacy in terms of four evaluation questions and outcome measures identified by program users from eight Texas medical schools.

METHOD

The authors compared the proportion of 10,081 Texas medical school students graduating from 1992-2000 who chose family practice or other primary care residencies following participation or nonparticipation in the TSFPPP's preclinical and clinical programs.

RESULTS

The proportion of students choosing family practice residencies among TSFPPP participants was significantly greater than among nonparticipants. Participation in the TSFPPP was associated with an increased choice of a family practice residency for students who were involved in the TSFPPP at the preclinical level (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.41-1.87); the clinical level (OR, 2.31; 95% CI, 1.99-2.68); and both levels (OR, 4.98; 95% CI, 3.75-6.68) compared to non-TSFPPP participation. There was a 44% increase in preceptors willing to teach medical students.

CONCLUSIONS

Participation in the TSFPPP is associated with a greater likelihood of students selecting a family practice residency. The interinstitutional approach to analyzing effects of the preceptorship on students' specialty choices focuses attention on primary care issues that, in the long run, may affect an entire state's health care delivery system.

Electron Microscopy of Surface Smoothness of Porcine Corneas and Acrylic Plates With Four Brands of Excimer Laser

PURPOSE

This study compares ablation smoothness patterns produced on four different excimer laser devices available for photorefractive surgery.

METHODS

VISX calibration plastic and porcine cornea were ablated with standard -3.00-D, -6.00-D, and -9.00-D settings using four different excimer lasers: VISX S2 Smooth Scan, Nidek EC-5000, Autonomous Ladar Vision System, and Bausch and Lomb Technolas. Electron microscopy and laser interferometry were used for qualitative evaluation of the ablated surfaces. Corneal ablation surface smoothness was graded by ten independent observers. Calibration plastic ablated surfaces were evaluated quantitatively for smoothness by laser interferometry.

RESULTS

The independent observer assessment of corneal ablation surface smoothness demonstrated that the Autonomous small spot Gaussian profile laser produced the smoothest ablation surfaces, followed by the other broad beam lasers. In comparing ablation smoothness among various refractive powers (-9.00 D, -6.00 D, and -3.00 D), a trend was observed that indicated a correlation of higher refractive settings with decreasing surface smoothness. However, this trend was not statistically significant. The quantitative laser interferometry measurements supported the independent observer ranking of the Autonomous flying small spot ablation profile as the smoothest. However, there were differences between the laser interferometry smoothness rankings and independent observer smoothness rankings.

CONCLUSION

There were significant differences in ablation surface smoothness among the four excimer lasers tested.

A paediatric trial comparing midazolam/Syrpalta mixture with premixed midazolam syrup (Roche)

BACKGROUND

The bitter taste of midazolam is more acceptable to children when the drug is mixed with fruit juice or syrup. We use a thick grape syrup (Syrpalta), and children are sedated in 10-15 min. A premixed cherry-flavoured midazolam solution (Roche), 2 mg.ml (-1), is currently available. It has been our impression that the premixed midazolam has a slower onset of action. Our aim was to evaluate the effects of the midazolam mixtures (midazolam 0.5 mg.kg (-1), 2 mg.ml (-1)) on children's anxiety, sedation, separation anxiety, mask acceptance, and recovery time.

METHODS

Seventy-six healthy children, 1-4 years of age, scheduled for elective placement of ear tubes, were enrolled. The trial was double-blinded and randomized. For premedication, one group received the premixed midazolam, and a second group received the midazolam/Syrpalta mixture. An independent blinded observer evaluated the children, using anxiety and sedation scales at baseline, at 5, 10 and 15 min and at parental separation. Mask acceptance and awakening time were evaluated.

RESULTS

Children who received the midazolam/Syrpalta mixture had less anxiety at 15 min (P = 0.046) and at parental separation (P < 0.001) than those who received the premixed midazolam solution. Mask acceptance was not different.

CONCLUSIONS

We concluded that the midazolam/Syrpalta mixture has a faster onset of action than the premixed midazolam solution.

Quantitative assessment of aqueous flare: the effect of age and pupillary dilation

OBJECTIVE

To assess the effect of age and pupillary dilation on aqueous flare.

METHODS

In this study, 100 eyes of 100 patients ranging in ages from 23 to 84 years were examined. Anterior chamber flare was measured before and after pupillary dilation using the Kowa laser flare meter (FM-500). Predilation and postdilation flare counts were compared by paired t-test. Stepwise regression analysis was then used to determine the effect of demographic variables on pre- and postdilation flare as well as the difference between pre-and postdilation flare counts.

RESULTS

The predilation and postdilation flare counts correlated with age (P < 0.0001 for both pre-and postdilation flare counts). Correlation coefficient between age and flare measurements was R2 = 0.58 predilation and 0.63 postdilation. Flare intensity significantly decreased after pupillary dilation (P < 0.001).

CONCLUSIONS

Anterior chamber flare increases with age. It might be related to blood-aqueous barrier instability. Pupillary dilation significantly decreases flare counts suggesting that aqueous protein concentration is dependent on aqueous flow rates.

Laser Epithelial Keratomileusis for Myopia With the Autonomous Laser

PURPOSE

To describe the refractive outcome, objective clinical data, and subjective patient experiences after laser epithelial keratomileusis (LASEK) at 1, 3, and 6 months after surgery.

METHODS

This was a retrospective, nonrandomized, comparative study of 58 LASEK-treated eyes (36 patients) with myopia (with and without astigmatism) between -1.50 and -14.75 D (mean -7.80 +/- 2.90 D, median -7.90 D). Refractive surgery was performed using the Alcon Summit Autonomous LADAR Vision excimer laser. Manifest refraction, best-spectacle and uncorrected Snellen visual acuity, stability of refraction, and corneal haze were evaluated before surgery and up to 6 months after surgery. A group of randomly selected LASIK-treated eyes were compared at each time point.

RESULTS

Patients who opted for monovision (n=12) were excluded. In the emmetropia targeted eyes (n=46), 45%, 83%, 85%, and 89% achieved 20/40 or better uncorrected Snellen visual acuity (UCVA) at 1 day, 1 week, 2 weeks, and 1 month respectively. At 6 months, 73% (n=28) of eyes treated achieved UCVA 20/20 with 97% achieving 20/40 or better (mean, -0.51 D). At 3 and 6 months, 71% (n=46) and 68% (n=28) were within +/- 0.50 D of emmetropia. The percentage of eyes that achieved UCVA 20/40 or better at 6 months was 97% (n=28). Visually significant corneal haze was evident in two LASEK-treated patients (four eyes) at 6 months. No eyes lost two or more lines of best spectacle-corrected Snellen visual acuity.

CONCLUSIONS

Preliminary data suggest that LASEK appears to be a safe, effective, and comparable alternative to LASIK, even for higher amounts of myopia. A prospective, randomized clinical trial is needed to better define the role of LASEK as it compares to other refractive procedures, specifically LASIK and PRK.

Assessment of anterior chamber flare and cells after laser in situ keratomileusis

PURPOSE

To determine the presence of anterior chamber flare and cells after laser in situ keratomileusis (LASIK) for the correction of myopia.

SETTING

Hermann Eye Center and the University of Texas Medical School, Department of Ophthalmology and Visual Science, Houston, Texas, USA.

METHODS

Forty-three eyes of 23 consecutive patients ranging in age from 24 to 62 years had LASIK for myopia. All surgeries were performed by a single surgeon using a VISX Star laser and the same technique. Patients received no preoperative antiinflammatory medications. Postoperatively, all patients were instructed to use 1 drop of ofloxacin (Ocuflox) and 1 drop of fluorometholone 0.1% (FML) in the operated eye 4 times daily while awake for 7 days. At baseline and postoperative days 1, 7, and 28, anterior chamber flare was measured and cells were counted using a Kowa laser flare meter (FM-500) and laser cell counter (LC-500), respectively.

RESULTS

Flare and cells increased significantly on day 1 (P <.0001 for both flare and cells) and returned to preoperative levels by day 7. No statistically significant correlation was detected between the amount of inflammation and the number of laser pulses (P =.2922) or the ablation time (P =.8383).

CONCLUSIONS

A significant increase in anterior chamber inflammation occurred during the first 24 hours after LASIK. Inflammation levels then subsided to preoperative levels by day 7 with steroid use. Anterior chamber inflammation did not appear to correlate with the duration of the ablation or the number of laser pulses.