A vascular syphilitic iris lesion

Purpose

To describe examination and imaging characteristics of presumed iris papulosa in a case of ocular syphilis.

Observations

A 60-year-old man who presented with granulomatous anterior uveitis in his left eye was also noted to have an unusual vascularized iris papule associated with posterior synechiae at the nasal pupillary margin. Anterior segment OCT (AS-OCT) of the iris lesion demonstrated a hyperreflective anterior surface with multiple vascular lumen, internal hyperreflectivity, and shadowing. Ultrasound biomicroscopy (UBM) imaging revealed an echodense mass with relative hyperechogenicity in the anterior portion of the lesion. Systemic work-up confirmed a diagnosis of syphilis, and he was treated with topical steroids and parenteral penicillin.

Conclusion and Importance

We characterize the rare finding of iris papulosa that may be encountered in syphilitic uveitis and its distinctive features on both UBM and AS-OCT. This report highlights that syphilis should be considered as a possible diagnosis for an undifferentiated vascular iris mass.

Cauda equina thickening: an approach to MRI findings

There are many causes of cauda equina (CE) thickening on neuroimaging of the lumbar spine. The imaging features of CE thickening for the various conditions often overlap and are non-specific to clinch a definite diagnosis. Hence, the imaging findings have to be discerned in accordance with the patient's presenting history, clinical examination findings, and results from electrophysiology and laboratory studies. In this review, the authors aim to supplement the existing literature on imaging findings of CE thickening with a diagnostic framework for clinical workup. The authors also aim to familiarise readers with the interpretation of CE thickening on magnetic resonance imaging (MRI) and would like to illustrate the normal variants and pitfalls that could be mistaken for abnormal results.

Communication in youth mental health clinical encounters: Introducing the agential stance

When young people seek support from mental health care practitioners, the encounters may affect the young people's sense of self, and in particular undermine their sense of agency. For this study, an interdisciplinary team of academics and young people collaboratively analysed video-recorded encounters between young people and mental healthcare practitioners in emergency services. They identified five communication techniques that practitioners can use to avoid undermining the young person's sense of agency in the clinical encounter. They conceptualise the use of those techniques as the adoption of an agential stance towards the young person. The agential stance consists of: (a) validating the young person's experiences, (b) legitimising the young person's choice to seek help, (c) refraining from objectifying the young person, (d) affirming the young person's capacity to contribute to positive change, and (e) involving the young person in the decision-making process.

Anxiety, stress, and binge eating tendencies in adolescence: a prospective approach

BACKGROUND

Recent years have witnessed an increasing prevalence of binge eating tendencies in adolescence-warranting a clearer understanding of their underlying predisposing and precipitating factors. The current study investigated whether the interaction between high levels of anxiety and stress predicted increased levels of binge eating tendencies in a prospective cohort of adolescents (N = 324).

METHODS

Measurements were taken over three waves (M ages: 13.33, 14.48, 15.65) as part of the CogBIAS Longitudinal Study. Longitudinal associations between levels of anxiety and stress with binge eating tendencies were estimated using a random intercept cross-lagged panel model (RI-CLPM), which calculates within-person fluctuations over time while accounting for individual trait-like stability and between-person variations. Binge eating tendencies were measured by the Cognitive Restraint, Uncontrolled Eating, and Emotional Eating styles from the Three-Factor Eating Questionnaire-R18. Two models were created for each binge eating tendencies variable: (1) a basic model with anxiety and stress as independent variables; (2) an interaction model with an additional anxiety*stress interaction term. Model fit was assessed by SEM fit indices: X², CFI, NFI, TLI, RMSEA, SRMR. Superior model fit was ascertained by a chi-square difference test (p < .05).

RESULTS

For Cognitive Restraint, the interaction model demonstrated superior fit to the data (p < .05). The anxiety*stress interaction at Waves 1 and 2 was significantly negatively associated with Cognitive Restraint at Waves 2 (β = -0.18, p = .002) and 3 (β = -0.14, p = .002)-suggesting that anxiety and stress interacted to predict increased binge eating tendencies linked with cognitive restraint over and above their independent effects. In contrast, the interaction term between anxiety*stress did not predict levels of Uncontrolled Eating or Emotional Eating over time.

CONCLUSIONS

The results highlight the importance of increasing awareness of the interaction between concurrently high anxiety and stress as a potential risk factor for binge eating tendencies in young people.

TRIAL REGISTRATION

Not applicable.

Identification and disruption of a neural mechanism for accumulating prospective metacognitive information prior to decision-making

More than one type of probability must be considered when making decisions. It is as necessary to know one's chance of performing choices correctly as it is to know the chances that desired outcomes will follow choices. We refer to these two choice contingencies as internal and external probability. Neural activity across many frontal and parietal areas reflected internal and external probabilities in a similar manner during decision-making. However, neural recording and manipulation approaches suggest that one area, the anterior lateral prefrontal cortex (alPFC), is highly specialized for making prospective, metacognitive judgments on the basis of internal probability; it is essential for knowing which decisions to tackle, given its assessment of how well they will be performed. Its activity predicted prospective metacognitive judgments, and individual variation in activity predicted individual variation in metacognitive judgments. Its disruption altered metacognitive judgments, leading participants to tackle perceptual decisions they were likely to fail.

A Comparison of Trabeculectomy Surgery Outcomes With Mitomycin-C Applied by Intra-Tenon Injection Versus Sponge

PURPOSE

To compare the outcomes of mitomycin-C (MMC) delivered by intra-Tenon injection vs sponge application during trabeculectomy surgery.

METHODS

We retrospectively reviewed 566 patients with primary and secondary glaucoma diagnoses who received trabeculectomy surgery with MMC in an academic medical center. Exclusion criteria were age less than 18 years, no light perception vision, combined surgery, previous glaucoma incisional surgery, intraoperative 5-fluorouracil, or follow-up <1 month. Subjects were divided into 2 cohorts: MMC delivered by sponge application or by intra-Tenon injection. Main outcome measures were postoperative intraocular pressure (IOP) level and secondary measures were survival rate for IOP control, glaucoma medication use, complication rate, and vision.

RESULTS

After inclusion/exclusion criteria, 316 eyes were available for analysis; 131 eyes had MMC delivered via sponge and 185 eyes via injection. Mean postoperative IOP was not significantly different between treatment groups but change in IOP from baseline was lower in the sponge vs the injection group 24 months after surgery (P = .038). The MMC sponge group had significantly more tense, vascularized, or encapsulated blebs as a late complication (P = .046). Time to failure for postoperative IOP control was not significantly different between MMC treatment groups, but older patient age and limbus-based conjunctival incision were associated with significantly longer time to fail.

CONCLUSIONS

The application of MMC by injection was similar to application by sponge in lowering IOP in patients with glaucoma and the safety of both techniques appears to be comparable. Limbus-based conjunctival incision had longer time to failure for postoperative IOP control vs fornix-based incision. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Cost Analysis of Teleophthalmology Screening for Diabetic Retinopathy Using Teleophthalmology Billing Codes

BACKGROUND AND OBJECTIVE

To evaluate the financial sustainability of teleophthalmology screening for diabetic retinopathy (DR) using telehealth billing codes.

PATIENTS AND METHODS

The authors performed an Institutional Review Board-approved retrospective review of medical records, billing data, and quality metrics at the University of California Davis Health System from patients screened for DR through an internal medicine-based telemedicine program using CPT codes 92227 or 92228.

RESULTS

A total of 290 patients received teleophthalmology screening over a 12-month period, resulting in an increase in the DR screening rate from 49% to 63% (P < .0001). The average payment per patient was $19.86, with an estimated cost of $41.02 per patient. The projected per-patient incentive bonus was $43.06 with a downstream referral revenue of $39.38 per patient. One hundred seventy-eight clinic visits were eliminated, providing an estimated cost savings of $42.53 per patient.

CONCLUSION

Sustainable teleophthalmology screening may be achieved by billing telehealth codes but only with health care incentive bonuses, patient referrals, and by accounting for the projected cost-savings of eliminating office visits. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S26-S34.].

Retinal Detachment: Patient Perspective and Electronic Health Records

PURPOSE

To provide a first-hand account of a retinal detachment suffered by one of the authors and how it relates to electronic health record (EHR) interoperability.

DESIGN

Single-patient, observational.

METHODS

1) Personal patient perspective - symptom, surgery, recovery and the worry about potential long lasting sequelae, and the need to reiterate detailed medical information several times during a stressful period. 2) U.S. National perspective regarding EHRs.

SETTING

Out-patient and community hospital. Patient or Study Population: Single patient. Intervention or Observation Procedure(s): Retinal surgery.

MAIN OUTCOME MEASURE(S)

Visual acuity.

RESULTS

Patient had a favorable outcome, but was required to provide medical history data multiple times to multiple providers. Only 41% of hospitals in the United States have EHR from outside providers or sources when treating a patient. Physicians in outpatient settings fare worse with only 14% of office-based physicians sharing data with providers outside of their organization.

CONCLUSIONS

While adoption and use of EHRs are incentivized by the federal government in the United States, the lack of interoperability between different physician and hospital systems means that we are far from achieving meaningful digitization of records. This case report provides a close look at how it may be difficult to receive care in a fragmented health care model in which physician and hospital do not share the same EHR. Information blocking, now prohibited by federal law, still remains an obstacle to interoperability. It will take continued effort and commitment from key stakeholders such as health care providers, patients, the federal government, and industry to bring this dream to fruition.

Adoption of Electronic Health Records and Perceptions of Financial and Clinical Outcomes Among Ophthalmologists in the United States

Importance

Assessing the rate of electronic health record (EHR) adoption and ophthalmologists' perceptions on financial and clinical productivity is important in understanding how to direct future design and health care policy.

Objective

To assess adoption rate and perceptions of financial and clinical outcomes of EHRs among ophthalmologists in the United States.

Design, Setting, and Participants

Population-based, cross-sectional study. A random sample of 2000 ophthalmologists was generated on the basis of mailing address zip codes from the 2015 American Academy of Ophthalmology US active membership database, which included more than 18 000 ophthalmologists. A survey was sent by email to assess adoption rate of EHRs, perceptions of financial and clinical productivity, and engagement with Medicare and Medicaid programs that incentivize the use of EHRs. The survey was conducted between 2015 and 2016.

Main Outcomes and Measures

Adoption rate of EHRs and perceptions of financial and clinical productivity.

Results

The adoption rate of EHRs among surveyed ophthalmologists (348 respondents) was 72.1%. The responding ophthalmologists perceived that their net revenues and productivity have declined and that practice costs are higher with EHR use. Of those who attested for stage 1 of the EHR incentive program, 83% had already or were planning to attest to stage 2, but 9% had no plans.

Conclusions and Relevance

The adoption of EHRs by ophthalmologists has more than doubled since a 2011 survey and is similar to that of primary care physicians (79%). In comparison with 2 previous surveys of ophthalmologists, respondents had more negative perceptions of EHR productivity outcomes and effect on practice costs, although financial data were not collected in this survey to support these opinions. These negative perceptions suggest that more attention should be placed on improving the efficiency and usability of EHR systems.

Epithelial downgrowth after femtosecond laser-assisted cataract surgery

Purpose

To present the case of a 72-year-old female with epithelial downgrowth after femtosecond laser-assisted cataract surgery.

Observations

The patient previously underwent YAG vitreolysis after uncomplicated femtosecond laser-assisted cataract surgery and presented 1 year later with epithelial downgrowth causing complete pupillary block and severe angle closure glaucoma. Subsequent management with nd:YAG peripheral iridotomies failed rapidly leading to a confusing presentation with a flat anterior chamber and high intraocular pressure ultimately requiring surgical management.

Conclusions

We describe the occurrence of epithelial downgrowth after femtosecond laser-assisted cataract surgery and illustrate the utility of ultrasound biomicroscopy to differentiate between severe pupillary block and malignant glaucoma.

Unusual case of lipoma arborescens in the subacromial-subdeltoid bursa

A 38-year-old female presented with a 10-month history of right shoulder pain with impingement symptoms. She was diagnosed on magnetic resonance (MR) imaging to have supraspinatus tendon tear and degenerative changes contributing to subacromial impingement. She also had lipoma arborescens of the subacromial-subdeltoid bursa, an uncommon condition in a particularly rare location. Lipoma arborescens is a benign intra-articular condition characterized by lipomatous proliferation of synovium with replacement of subsynovial tissue by mature adipocytes. It is typically a monoarticular process affecting the knee. Due to the presence of pathognomonic fat, diagnosis is usually straightforward with MR as the preferred imaging modality.

The impact of conversion to International Classification of Diseases, 10th revision (ICD-10) on an academic ophthalmology practice

Purpose

To determine the financial and clinical impact of conversion from International Classification of Disease, 9th revision (ICD-9) to ICD-10 coding.

Design

Retrospective, database study.

Materials and methods

Monthly billing and coding data from 44,564 billable patient encounters at an academic ophthalmology practice were analyzed by subspecialty in the 1-year periods before (October 1, 2014, to September 30, 2015) and after (October 1, 2015, to September 30, 2016) conversion from ICD-9 to ICD-10.

Main outcomes and measures

Primary outcome measures were payments per visit, relative value units per visit, number of visits, and percentage of high-level visits; secondary measures were denials due to coding errors, charges denied due to coding errors, and percentage of unspecified codes used as a primary diagnosis code.

Results

Conversion to ICD-10 did not significantly impact payments per visit ($306.56±$56.50 vs $321.43±$38.12, P=0.42), relative value units per visit (7.15±0.56 vs 7.13±0.84, P=0.95), mean volume of visits (1,887.08±375.02 vs 1,863.83±189.81, P=0.71), or percentage of high-level visits (29.7%±4.9%, 548 of 1,881 vs 30.0%±1.7%, 558 of 1,864, P=0.81). For every 100 visits, the number of coding-related denials increased from 0.98±0.60 to 1.84±0.31 (P<0.001), and denied charges increased from $307.42±$443.39 to $660.86±$239.47 (P=0.002). The monthly percentage of unspecified codes used increased from 25.8%±1.1% (485 of 1,881) to 35.0%±2.3% (653 of 1,864, P<0.001).

Conclusion

The conversion to ICD-10 did not impact overall revenue or clinical volume in this practice setting, but coding-related denials, denied charges, and the use of unspecified codes increased significantly. We expect these denials to increase in the next year in the absence of Medicare’s 1-year grace period.

Abstract P4-06-12: Different patterns of risk reducing decisions in affected or unaffected BRCA mutation carriers

BACKGROUND

Risk-reducing (RR) management decreases the risk of breast cancer and BRCA related gynecologic cancer. However, there are fewer reports on the RR management in Asia compared to Western countries.The aim of this study is to identify risk reducing management patterns with BRCA1 or BRCA2 mutation carriers.

METHODS

The study group consisted of all consecutive 1104 breast cancer, ovarian patients and their families of high-risk patients who underwent BRCA gene testing in National Cancer Center, Korea from 2008 to 2016. A total 220 BRCA mutations (19.9%) were detected with 125(11.3%) of BRCA1 gene and 95 (8.6%) of BRCA2 gene.

RESULTS

Out of 220 BRCA mutations carriers, they were consisted of 83 breast cancers, 10 ovarian cancers, 7 both cancers, and 120 unaffected carriers. Among them, 42 were men and 178 were women. About 90 % (198/ 220) had the familial history of breast, ovarian or both malignancies (113 in BRCA1 and 85 in BRCA2 mutation (p=0.821)).

All 42 men chose surveillance. Among 178 female BRCA mutation carriers, 98(55.1%) underwent risk reducing management including 18(10.1%) of chemoprevention, and 80(49.9%) had risk-reducing surgeries (RRSs) (1 case of risk-reducing mastectomy, 76 of risk reducing bilateral salphingo-oophorectomy (RRSO), and 3 of both) and 80 (54.9%) chose only intensive surveillance for both of breast and ovary cancer.

In affected carriers with breast cancer, 59 (71.1%) underwent RR management (1 case of risk reducing mastectomy, 53 of RRSO, 3 of both surgery, and 2 of chemoprevention). There was no risk reducing management in affected carrier with ovarian cancer patients. In 78 unaffected women carriers, 39(50.0%) women received RR management (23(29.5%) cases of RRSO and 16(20.5%) cases of chemoprevention). The rates of RRSs have increased annually since the 2013 year, (prior to 2013 vs. since 2013, RRSs 28.6% (6 cases/21 carriers) vs. 37.2% (74/199), p&lt;0.01).

CONCLUSION

This study was conducted on the largest numbers of BRCA mutation carriers in Asian countries. RRSO is the more preferred management for affected carriers with breast cancer or unaffected carriers. The results might be explained by the severity of the illness and that RRSO was only reimbursed RR strategy from the Korean Government Insurance. Tailored genetic counseling and insurance policy may enhance overall levels of RR management.

Citation Format: Lee EG, Kang H, Park SJ, Han JH, Jung S-Y, Lee S, Kang H-S, Park B, Kong S-Y, Lim MC, Park S-Y, Lee ES. Different patterns of risk reducing decisions in affected or unaffected BRCA mutation carriers [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-06-12.

Primary Open-Angle Glaucoma Preferred Practice Pattern(®) Guidelines

PRIMARY OPEN-ANGLE GLAUCOMA PREFERRED PRACTICE PATTERN®

GUIDELINES

Evidence-based update of the Primary Open-Angle Glaucoma Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary open-angle glaucoma with an algorithm for patient management and detailed recommendations for evaluation and treatment options.

Primary Angle Closure Preferred Practice Pattern(®) Guidelines

PRIMARY ANGLE CLOSURE PREFERRED PRACTICE PATTERN®

GUIDELINES

Evidence-based update of the Primary Angle Closure Preferred Practice Pattern® (PPP) guidelines, describing the diagnosis and management of patients with primary angle closure with detailed recommendations for evaluation and treatment options.

CT volumetry of the liver: where does it stand in clinical practice?

Imaging-based volumetry has been increasingly utilised in current clinical practice to obtain accurate measurements of the liver volume. This is particularly useful prior to major hepatic resection and living donor liver transplantation where the size of the remnant liver and liver graft, respectively, affects procedural success and postoperative mortality and morbidity. The use of imaging-based volumetry, with emphasis on computed tomography, will be reviewed. We will explore the various technical factors that contribute to accurate volumetric measurements, and demonstrate how the accuracies of these techniques are influenced by their methodologies. The strengths and limitations of using anatomical imaging to estimate liver volume will be discussed, in relation to laboratory and functional imaging methods of assessment.

Adoption of electronic health records and preparations for demonstrating meaningful use: an American Academy of Ophthalmology survey

OBJECTIVE

To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate, user satisfaction, functionality, benefits, barriers, and knowledge of meaningful use criteria.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 492 members of the American Academy of Ophthalmology (AAO).

METHODS

A random sample of 1500 AAO members were selected on the basis of their practice location and solicited to participate in a study of EHR use, practice management, and image management system use. Participants completed the survey via the Internet, phone, or fax. The survey included questions about the adoption of EHRs, available functionality, benefits, barriers, satisfaction, and understanding of meaningful use criteria and health information technology concepts.

MAIN OUTCOME MEASURES

Current adoption rate of EHRs, user satisfaction, benefits and barriers, and availability of EHR functionality.

RESULTS

Overall, 32% of the practices surveyed had already implemented an EHR, 15% had implemented an EHR for some of their physicians or were in the process of implementation, and another 31% had plans to do so within 2 years. Among those with an EHR in their practice, 49% were satisfied or extremely satisfied with their system, 42% reported increased or stable overall productivity, 19% reported decreased or stable overall costs, and 55% would recommend an EHR to a fellow ophthalmologist. For those with an electronic image management system, only 15% had all devices integrated, 33% had images directly uploaded into their system, and 12% had electronic association of patient demographics with the image.

CONCLUSIONS

The adoption of EHRs by ophthalmology practices more than doubled from 2007 to 2011. The satisfaction of ophthalmologists with their EHR and their perception of beneficial effects on productivity and costs were all lower in 2011 than in 2007. Knowledge about meaningful use is high, but the percentage of physicians actually receiving incentive payments is relatively low. Given the importance of imaging in ophthalmology, the shortcomings in current image management systems need to be addressed.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

High control rate for lymph nodes in cervical cancer treated with high-dose radiotherapy using helical tomotherapy

The purpose of this study was to evaluate whether bulky lymphadenopathy located in the abdominopelvic cavity in cervical cancer can be controlled without severe toxicity by increasing radiation dose using helical tomotherapy. From January 2007 to December 2010, 26 patients with cervical cancer with metastatic lymph nodes (LNs) having at least one short diameter > 1.5 cm were treated with helical tomotherapy. A total of 58 LN sites were treated and the largest LN of each site was evaluated for response. Median follow-up time was 28 months (4-50 months). Median short diameter of the LNs was 1.7 cm (0.7-4.2 cm) with median radiation dose of 62.6 Gy(10) in 2 Gy equivalent dose (53.3-77.9 Gy(10)). Initial LN response was evaluated on imaging obtained within 4 months after radiotherapy. Initial complete response (CR), partial response (PR), and stable disease (SD) were observed in 54, 2 and 2 lesions, respectively. Recurrence occurred in two with CR and progression in one with PR. Therefore, final CR, PR, SD, and progression of disease were observed in 52, 1, 2, and 3, respectively. Actuarial 3-year LN progression-free survival and overall survival (OS) were 63% and 65%, respectively. Multivariate analysis revealed final LN response (CR vs. non-CR) as a strong prognostic factor for OS (p = 0.016). Radiation Therapy Oncology Group grade 2 or more acute and late toxicity was observed in 8 and 1 patients, respectively. The treatment of bulky lymphadenopathy using helical tomotherapy in advanced cervical cancer is highly effective and has acceptable toxicity.

Long-term complications associated with glaucoma drainage devices and Boston keratoprosthesis

PURPOSE

To evaluate long-term complications related to glaucoma drainage devices in patients undergoing Boston type 1 keratoprosthesis surgery.

DESIGN

Retrospective case series.

METHODS

All patients who underwent Boston type 1 keratoprosthesis surgery at the University of California, Davis, between 2004 and 2010 were included. Preoperative and postoperative data were reviewed. Twenty-five eyes with glaucoma drainage devices were highlighted. Visual acuity and postoperative complications were tracked at postoperative months 1, 3, 6, 9, and 12 and at annual intervals thereafter.

RESULTS

Forty eyes of 35 patients were evaluated with an average follow-up of 33.6 months. Conjunctival breakdown occurred in association with 10 glaucoma drainage device implants in 9 eyes. Eleven eyes had glaucoma drainage devices placed before keratoprosthesis surgery, 3 eyes underwent glaucoma drainage device placement at the time of surgery, and 2 eyes had a glaucoma drainage device placed after surgery. All but one of the eroded glaucoma drainage devices were placed before surgery. Associated complications included endophthalmitis, hypotony, and keratoprosthesis extrusion, with 6 glaucoma drainage devices requiring removal. Long-term beset-corrected visual acuity was maintained better in eyes in which glaucoma drainage device erosions did not develop.

CONCLUSIONS

One of the main challenges with keratoprosthesis surgery is treating concurrent glaucoma. Glaucoma drainage devices have been advocated as a way to address this long-term complication, but this series suggests that glaucoma drainage device-related complications can cause significant vision loss.

Special requirements for electronic health record systems in ophthalmology

The field of ophthalmology has a number of unique features compared with other medical and surgical specialties regarding clinical workflow and data management. This has important implications for the design of electronic health record (EHR) systems that can be used intuitively and efficiently by ophthalmologists and that can promote improved quality of care. Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists. The purpose of this article is to summarize the special requirements of EHRs that are important for ophthalmology. The hope is that this will help ophthalmologists to identify important features when searching for EHR systems, to stimulate vendors to recognize and incorporate these functions into systems, and to assist federal agencies to develop future guidelines regarding meaningful use of EHRs. More broadly, the American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk, and ultimately will improve the ability of physicians to deliver the highest-quality medical care.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial interest disclosure may be found after the references.

Evidence of outer retinal changes in glaucoma patients as revealed by ultrahigh-resolution in vivo retinal imaging

AIMS; It is well established that glaucoma results in a thinning of the inner retina. To investigate whether the outer retina is also involved, ultrahigh-resolution retinal imaging techniques were utilised.

METHODS

Eyes from 10 glaucoma patients (25-78 years old), were imaged using three research-grade instruments: (1) ultrahigh-resolution Fourier-domain optical coherence tomography (UHR-FD-OCT), (2) adaptive optics (AO) UHR-FD-OCT and (3) AO-flood illuminated fundus camera (AO-FC). UHR-FD-OCT and AO-UHR-FD-OCT B-scans were examined for any abnormalities in the retinal layers. On some patients, cone density measurements were made from the AO-FC en face images. Correlations between retinal structure and visual sensitivity were measured by Humphrey visual-field (VF) testing made at the corresponding retinal locations.

RESULTS

All three in vivo imaging modalities revealed evidence of outer retinal changes along with the expected thinning of the inner retina in glaucomatous eyes with VF loss. AO-UHR-FD-OCT images identified the exact location of structural changes within the cone photoreceptor layer with the AO-FC en face images showing dark areas in the cone mosaic at the same retinal locations with reduced visual sensitivity.

CONCLUSION

Losses in cone density along with expected inner retinal changes were demonstrated in well-characterised glaucoma patients with VF loss.

Effect of diabetic retinopathy and panretinal photocoagulation on retinal nerve fiber layer and optic nerve appearance

OBJECTIVE

To determine if panretinal photocoagulation (PRP) alters retinal nerve fiber layer (RNFL) thickness and optic nerve appearance.

METHODS

Patients with diabetes who did and did not undergo PRP and nondiabetic control subjects were enrolled in a prospective study. Participants underwent optical coherence tomography of the peripapillary retina and optic nerve. Stereoscopic optic nerve photographs were graded in a masked fashion.

RESULTS

Ninety-four eyes of 48 healthy individuals, 89 eyes of 55 diabetic patients who did not undergo PRP, and 37 eyes of 24 subjects with diabetes who underwent PRP were included in this study. Eyes that had been treated with PRP had thinner peripapillary RNFL compared with the other groups; this was statistically significantly different in the inferior (P = .004) and nasal (P = .003) regions. Optic nerve cupping did not increase with severity of disease classification, but the proportion of optic nerves graded as suspicious for glaucoma or as having nonglaucomatous optic neuropathy did (P = .008). These grading categories were associated with thinner RNFL measurements.

CONCLUSIONS

Diabetic eyes that have been treated with PRP have thinner RNFL than nondiabetic eyes. Optic nerves in eyes treated with PRP are more likely to be graded as abnormal, but their appearance is not necessarily glaucomatous and may be related to thinning of the RNFL.

Laparoscopic and laparotomic staging in stage I epithelial ovarian cancer: a comparison of feasibility and safety

The aim of this study was to compare laparoscopic and laparotomic surgical staging in patients with stage I epithelial ovarian cancer in terms of feasibility and safety. A retrospective chart review was undertaken of all patients with apparent stage I epithelial ovarian cancer who underwent laparoscopic (laparoscopy group) or laparotomic (laparotomy group) surgical staging at the Center for Uterine Cancer, National Cancer Center, Korea, between January 2001 and August 2006. During the study period, 19 patients underwent laparotomic surgical staging and 17 patients underwent laparoscopic surgical staging. No cases were converted from laparoscopy to laparotomy. The two groups were similar in terms of age, body mass index, procedures performed, number of lymph nodes retrieved, and operating time. The laparoscopy group had less estimated blood loss (P = 0.001), faster return of bowel movement (P < 0.001), and a shorter postoperative hospital stay (P = 0.002) compared to the laparotomy group. Transfusions were required only in two laparotomy patients, and postoperative complications occurred only in four laparotomy patients. However, two patients with stage IA grade 1 and 2 disease in laparoscopy group had recurrence with one patient dying of disease. The accuracy and adequacy of laparoscopic surgical staging were comparable to laparotomic approach, and the surgical outcomes were more favorable than laparotomic approach. However, the oncologic safety of laparoscopic staging was not certain. This is the first report on the possible hazards of laparoscopic staging in early-stage ovarian cancer. In the absence of a large prospective trial, this technique should be performed cautiously.

Port-site and liver metastases after laparoscopic pelvic and para-aortic lymph node dissection for surgical staging of locally advanced cervical cancer

Recently, we experienced a case of port-site and liver metastases after 75 cases of laparoscopic transperitoneal pelvic lymph node dissection (PLND) and para-aortic lymph node dissection (PALND) for surgical staging of locally advanced cervical cancer. A 45-year-old-woman with stage IIB cervical adenocarcinoma underwent laparoscopic PLND and PALND for surgical staging. There was no intraperitoneal disease and cervical tumor was not manipulated at the time of laparoscopic surgery. Pathologic examination revealed only one micrometastasis in left internal iliac lymph node (LN), measuring 1 mm, of the 60 pelvic and para-aortic LNs removed. She received concurrent chemoradiation therapy and pelvic mass disappeared completely. One month after the completion of therapy, both lateral and umbilical port-site and liver metastases were detected. We conclude that although cases of port-site metastasis have mostly occurred after extensive disease, the possibility of such complication should be kept in mind at laparoscopy of early cancer and laparoscopy which does not manipulate primary tumor.

Long-term success in the correction of exposed glaucoma drainage tubes with a tube extender

PURPOSE

To report long-term success of surgical correction of exposed glaucoma drainage device (GDD) tubes with a commercially available tube extender.

DESIGN

Observational case series.

METHODS

Chart review of surgical correction for GDD tube exposure by rerouting the tube using the New World Medical Tube Extender (NWMTE; New World Medical, Rancho Cucamonga, California, USA).

RESULTS

Surgical revision of GDD tube exposure with the NWMTE controlled intraocular pressure without repeat exposure up to three years after surgery.

CONCLUSIONS

A tube extender can provide long-term correction of an exposed GDD tube by bypassing weakened tissue, thus avoiding or delaying a second implant surgery.

Nomogram-Based Intraocular Lens Power Adjustment after Myopic Photorefractive Keratectomy and LASIK

PURPOSE

(1) To evaluate the accuracy of nomogram-based adjustment of intraocular lens (IOL) power to achieve a desired refractive target after cataract surgery in postmyopic LASIK and photorefractive keratectomy (PRK) eyes and (2) to compare the accuracy of the nomogram-based method with the clinical history method.

DESIGN

Multicenter, retrospective, interventional, noncomparative case series.

SUBJECTS

Fourteen patients (19 eyes) after myopic LASIK or PRK with visually significant cataracts.

INTERVENTION

All eyes underwent cataract extraction and posterior chamber intraocular lens implantation. In each case, IOL power was determined with standard keratometry and biometry. Power adjustment was made by use of a theoretical nomogram followed by implantation.

MAIN OUTCOME MEASURES

(1) Final refraction and spherical equivalent after cataract surgery and (2) deviation of the final spherical equivalent from the refractive target.

RESULTS

After cataract extraction, by use of nomogram adjustment, 63.2% of eyes were within 0.5 D of the intended spherical equivalent, 84.2% were within 1.0 diopter of the intended spherical equivalent, and 100% were within 1.5 D of the intended spherical equivalent. The clinical history method was accurate in predicting the correct IOL power in 37.5% of cases, regardless of whether spectacle or corneal plane refraction was used.

CONCLUSIONS

(1) Given the change in spherical equivalent induced by myopic LASIK/PRK, IOL power can be adjusted accurately to avoid undercorrection without the need for the prerefractive surgery corneal power. (2) The nomogram-based method was more accurate than the clinical history method.

Glaucoma lasers: a review of the newer techniques

PURPOSE OF REVIEW

This paper serves to review the safety and efficacy of new laser techniques for the treatment of glaucoma with emphasis on those studies published within the past year.

RECENT FINDINGS

Recently published studies have reinforced the strong safety profile, and efficacy of selective laser trabeculoplasty (SLT). Endoscopic photocoagulation, while more technically challenging and more invasive, offers several advantages over transcleral cyclophotocoagulation including direct observation of treatment and therefore, fewer complications. Laser goniopuncture is a fledgling technology with, thus far, a good safety profile, and benefits that include conjunctival sparing and good treatment response. Many unanswered questions remain including long-term success rates and ideal treatment parameters.

SUMMARY

The benefits of laser in the treatment of glaucoma have been well established, and while some techniques will add to the ophthalmologists' armamentarium, others will fall into disuse as the efficacy and safety profiles of these procedures become recognized. Novel laser modalities, as well as the more traditional ones, require continued evaluation to further refine treatment parameters and to determine their long-term benefits.

The long-term results of keratoplasty in eyes with a glaucoma drainage device

PURPOSE

To study the outcome of penetrating keratoplasty (PK) in eyes with a glaucoma drainage device (GDD).

DESIGN

Retrospective case-controlled study.

METHODS

We reviewed all patients who underwent PK from December 1986 to September 2002 at the University of California, Davis (n = 1,974). We identified 33 patients (40 grafts) who were treated with a GDD and followed up for 6 months or more after PK. Graft survival and glaucoma control were compared with grafts in patients without glaucoma (n = 40) and patients with medically controlled glaucoma (n = 17). Kaplan-Meier survival analysis, log rank test, repeated-measures analysis of variance (ANOVA), Fisher exact test, and chi(2) were used in group comparisons. Multivariate analysis was performed using the Cox proportional hazards model.

RESULTS

The percentages of clear grafts in the glaucoma drainage device group were 58.5% and 25.8% at 1 and 2 years, respectively. At these time points, glaucoma was controlled in 74.0% and 63.1% of the eyes, respectively. Both medically controlled glaucoma patients and nonglaucomatous patients had higher graft survival percentages at comparable time points. The presence of a GDD was an important factor influencing graft survival (Hazard ratio = 6.8).

CONCLUSION

A GDD implant is an independent risk factor for graft failure. Although these devices are effective in controlling intraocular pressure (IOP) in the majority of eyes in the presence of PK, corneal graft clarity is often compromised.

Decreased macular leukocyte velocity in human immunodeficiency virus-infected individuals

PURPOSE

To determine whether human immunodeficiency virus (HIV)-infected individuals have decreased macular capillary blood flow in vivo.

DESIGN

Case control study.

METHODS

Macular leukocyte velocity and perceived leukocyte density were determined in 41 HIV-infected individuals without cytomegalovirus retinitis and 31 HIV-negative control subjects using the blue field simulation technique (BFS-2000, Oculix, Inc., Jenkintown, PA). Velocity and density measurements for HIV-infected individuals were compared to current and lowest previous CD4+ T-lymphocyte counts, HIV RNA blood levels, and blood leukocyte counts.

RESULTS

Mean macular leukocyte velocity was lower in HIV-infected individuals than in controls (P = 0.0006). No correlations were identified between velocity measurements and the following factors in HIV-infected individuals: current or lowest previous CD4+ T-lymphocyte count; or HIV RNA blood level. Mean perceived leukocyte density in HIV-infected individuals was lower than in controls (P = 0.003), but was not correlated with blood leukocyte count in HIV-infected individuals. No relationships were identified between macular leukocyte velocity and duration of medication use or duration of elevated CD4+ T-lymphocyte count in patients receiving potent antiretroviral therapy.

CONCLUSIONS

Reduced macular leukocyte velocity may have important implications for understanding the retinal microvasculopathy of HIV disease, the pathogenesis of opportunistic retinal infections, and visual dysfunction in HIV-infected individuals who do not have opportunistic retinal infections. We found no evidence that macular leukocyte velocity increased with immune reconstitution.

Late onset lens particle glaucoma as a consequence of spontaneous dislocation of an intraocular lens in pseudoexfoliation syndrome

PURPOSE

To report acute onset lens particle glaucoma associated with pseudoexfoliation-related dislocation of an intraocular lens implant 12 years after cataract surgery.

METHODS

Case report.

RESULTS

An 80-year-old woman presented with acute onset of left eye pain that was associated with white fleck-like particles circulating in the anterior chamber and an intraocular pressure of 48 mm Hg. The posterior chamber intraocular lens within the capsular bag was positioned more posteriorly to the iris plane than usual, and pseudoexfoliative material was present on the lens capsule and the zonules. Anterior chamber aspirate confirmed the presence of lens cortical fibers.

CONCLUSION

Spontaneous dislocation of the posterior chamber intraocular lens in patients with pseudoexfoliation syndrome several years after cataract surgery may liberate lens cortical material, causing lens particle glaucoma.

Depolarization counteracts glucocorticoid inhibition of adenohypophysical corticotroph cells

In AtT20 mouse corticotroph tumour cells large conductance Ca2+-activated K+-channels (BK-channels) have an essential role in the early glucocorticoid inhibition of adrenocorticotrophin (ACTH) secretion evoked by corticotrophin-releasing factor. The present study examined whether or not BK-channels are also pivotal to glucocorticoid inhibition of normal rat anterior pituitary cells. A membrane-permeant, non-metabolizable cyclic AMP analogue, 8-(4-Chlorophenylthio)adenosine-3',5'-cyclic-monophosphate (CPT-cAMP) was used as the primary secretagogue stimulus, as this mimics the increase of intracellular cyclic AMP caused by corticotrophin-releasing factor, but is not subject to the complex Ca2+-dependent regulation of cyclic AMP metabolism that is evident in corticotroph cells. Experiments in AtT20 cells showed that ACTH secretion stimulated by 1 mM CPT-cAMP was suppressed to 34+/-1.5% (n = 12) of the control stimulus by a maximal dose of 100 nM dexamethasone. The ACTH secretion evoked by the combination of 1 mM CPT-cAMP with either 5 microm (-)BayK8644 (L-type Ca2+-channel activator) or 5 mM TEA (K+-channel blocker) was respectively 69.1+/-7.6% and 69.3+/-11.8% of control after 2 h preincubation with 100 nM dexamethasone (P<0.05 vs CPT-cAMP). The ACTH response elicited by 5 microM (-)BayK8644 and 5 mM TEA given together was completely resistant to inhibition by 100 nM dexamethasone. Furthermore, TEA and (-)BayK8644 given together synergistically stimulated ACTH release in combination with 0.1 mM or 1 mM CPT-cAMP, and these ACTH responses were not inhibited by 100 nM dexamethasone. In primary cultures of rat anterior pituitary cells, TEA (up to 20 mM), charybdotoxin (30 nM) or apamin (100 nM) failed to modify the glucocorticoid inhibition of 0.1 mM CPT-cAMP-induced ACTH release. The combination of 5 mM TEA and 5 microM (-)BayK8644 elicited a small but significant increase in ACTH secretion but did not modify the inhibition of 0.3 mM CPT-cAMP-induced ACTH secretion by 100 nM dexamethasone. In primary cultures of rat anterior pituitary cells, depolarization of the membrane potential with 40 mM KCl enhanced the ACTH response to CPT-cAMP and markedly reduced the maximal inhibitory effect of dexamethasone to 55+/-1.2% as well as that of corticosterone to 33+/-2.1% vs 100+/-2.5% and 100+/-1.9% inhibition respectively, when 0.1 mM CPT-cAMP was used alone. Introduction of 5 microM (-)BayK8644 with 40 mM KCl in this system had no additional effect on glucocorticoid inhibition. No glucocorticoid inhibition of ACTH release to any of the stimuli applied was observed in cells pretreated with the mRNA synthesis inhibitor, 5,6-dichloro-furanosyl-benzimidazole riboside (DRB) (0.1 mM) or the protein synthesis blocker, puromycin (0.1 mM). In summary, early glucocorticoid inhibition of stimulated ACTH release by cultured rat anterior pituitary cells was dependent on the synthesis of new mRNA and protein. Depolarization of the membrane potential potentiated CPT-cAMP-induced ACTH secretion in AtT20 cells as well as cultured rat corticotrophs and this was associated with a resistance to the early inhibitory effect of glucocorticoids. Glucocorticoid inhibition in rat anterior pituitary corticotrophs was unaltered by TEA, charybdotoxin as well as apamin, and hence it is unlikely to involve predominantly BK-or SK-type Ca2+-activated K+-channels. These results support the thesis that a prime target of glucocorticoid feedback inhibition in anterior pituitary corticotrophs is the membrane potential and indicate that glucocorticoid-induced proteins regulate the activities of several distinct plasma membrane ion channels.

Clinical and echocardiographic features of mitral valve prolapse patients in a local population

Mitral valve prolapse (MVP) is a commonly diagnosed condition with varied clinical presentations but local data is lacking. In our study, we reviewed 98 patients (54 males, 44 females) with echocardiographic mitral valve prolapse diagnosed between 1991 and 1993 to study the clinical profile and echocardiographic features of patients with this condition in our local population. The mean and median age at presentation/detection were 42 years and 38 years respectively. The majority of the patients were asymptomatic (59%); the rest presented with palpitations (21%), congestive heart failure (4%) and infective endocarditis (5%). On clinical examination, 64 patients had mitral regurgitation (13 patients had both mitral regurgitation murmur and a systolic click), while one or more systolic clicks were heard in another 32 patients. Six patients also had associated Marfan syndrome. 2D echo revealed isolated anterior and posterior leaflet involvement in 55 and 19 patients respectively. Another 24 patients had involvement of both leaflets. Mitral regurgitation was detected on colour Doppler study in 78 patients. Nine patients had associated tricuspid valve prolapse. Of the 98 patients, 8 patients developed flail mitral valve. Four were detected at presentation/diagnosis, while the other 4 were diagnosed incidentally on routine follow-up 2D echo. Of these 8 patients, one developed cardiac failure. The patients had been on follow-up for a mean period of 9 months. During this period, mitral regurgitation progressed in 3 patients resulting in valve surgery. Only 20 patients had arrhythmias detected on ambulatory ECG monitoring, most of them were frequent atrial and ventricular premature beats. No patient was found to have haemodynamically significant arrhythmia. In summary, most patients with MVP had anterior mitral valve leaflet prolapse and mitral regurgitation. Although most patients with MVP are asymptomatic or have minor symptoms, it is associated with significant morbidity.

Effects of loratadine and terfenadine on the induced nasal allergic reaction

OBJECTIVE

To evaluate the effect of terfenadine and loratadine on the early nasal allergic response to challenge and the subsequent cellular influx and hyperresponsiveness.

DESIGN

Double-blind, placebo-controlled, triple-crossover study.

SUBJECTS

Fourteen, asymptomatic, allergic volunteers.

INTERVENTIONS

After an initial challenge with methacholine chloride, subjects received treatment with placebo, loratadine (10 mg by mouth daily), or terfenadine (60 mg by mouth twice daily) for 1 week, followed by a nasal allergen challenge with lavages; 24 hours later, while the subjects were still receiving medication, the quantity of cells in the nasal lavage was determined, and another challenge with methacholine was done. Mediator levels were quantified in the nasal lavages after the allergen c hallenge, and the weight of the methacholine-induced nasal secretions was measured.

RESULTS

Both loratadine and terfenadine treatment resulted in significant reductions in allergen-induced sneezing and the levels of histamine, kinins, albumin, and N-alpha-tosyl-L-arginine methyl ester-esterase activity in recovered nasal lavages compared with the reductions that resulted from placebo treatment, with no significant difference among the treatments. Treatment had no effect on the levels of tryptase, prostaglandin D2 or leukotriene C4. A significant eosinophil influx into nasal secretions 24 hours after the allergen challenge in patients who were receiving placebo (P=.006) was not affected by loratidine or terfenadine treatment. Comparing methacholine-induced secretions between screening challenges and challenges with the patients who were being treated with either loratadine or terfenadine, there was a significant decrease in secretions after the use of these antihistamines (P<.05).

CONCLUSION

Both loratadine and terfenadine partially inhibit the early nasal response to allergen challenge and the subsequent reactivity to a challenge with methacholine without affecting the influx of eosinophils into nasal secretions.

Diagnosis of deep vein thrombosis using duplex ultrasonography

Duplex ultrasonography is a safe, accurate, efficient, inexpensive, noninvasive diagnostic test for deep vein thrombosis (DVT). The sensitivity and specificity of this technique is comparable to venography in symptomatic patients in many studies. The diagnostic accuracy of this test can be further enhanced by serial studies. We report our experience with the use of this technique for study of 180 patients with clinically suspected DVT. Only 55 (30.6%) patients were confirmed to have DVT on duplex ultrasonography which illustrates the inaccuracy of bedside diagnosis of this potentially life-threatening condition. Almost all our DVT patients have proximal vein involvement, indicating that venous thrombosis usually do not cause signs or symptoms until they become large, occlusive and extend into the proximal veins. It is also observed in our study cohort that half of the patients with proximal vein thrombosis has incomplete recanalisation on follow-up study. None of them with normal study developed significant sequelae of untreated DVT, suggesting that it is safe to withhold treatment based on result of this non-invasive test. Duplex ultrasonography is the diagnostic modality of choice for suspected DVT in symptomatic patients and is an excellent substitute for conventional contrast venography.

Stenting of stenosis of the abdominal aorta

Isolated abdominal aortic stenosis resulting in bilateral lower limb claudication is uncommon in Asians. We report a 75-year-old Oriental man with isolated abdominal aortic stenosis who underwent intraluminal stenting, resulting in the abolishment of a 76 mmHg gradient. As the stenotic segment was local, only the mid-segment of the Palmaz stent was apposed to the aortic wall. Follow-up ultrasound scans showed that the partially apposed stent was potent, with no thrombosis in the free space between the stent and the wall. Hence, although aortic stenting in this patient resulted in partial apposition of the stent to the aortic wall, there was no thrombosis or migration of the stent. The patient remained symptom-free one year post-stenting. Stenting in this patient with failed balloon angioplasty was a safe and efficacious method of treating significant isolated abdominal aortic stenosis.

Vortex vein exit sites. Scleral coordinates

PURPOSE

The authors determined the frequency and scleral coordinates of vortex vein exit sites in 46 autopsy eyes to provide topographic data that will enable surgeons to locate these vessels more precisely.

METHODS

Forty-six autopsy eyes were examined under a dissecting microscope to measure the frequency of vortex veins and the cord lengths between the vortex vein scleral exit sites and the limbus, rectus muscle insertions, and oblique muscle insertions.

RESULTS

Data from this study showed that 32 (70%) of the 46 individual eyes studied had more than four vortex veins. The number of second or third vortex veins found in the nasal quadrants was significantly higher than the number found in the temporal quadrants (P < 0.01). Statistical analyses of the measurements provided mean values for distances between vortex vein scleral exit sites and the three nearest extraocular muscle insertions; these positions among eyes were found to be relatively uniform (standard deviation, 0.7-2.5 mm).

CONCLUSION

The authors suggest that the majority of adult eyes encountered by a surgeon will have more than four vortex vein exit sites and that more vortex veins may be expected in the nasal quadrants than in the temporal quadrants. This study delineates the locations of vortex vein exit sites so that surgeons can reliably predict their surface positions to avoid vessel laceration and its ensuing complications.