STRUCTURAL AND FUNCTIONAL MACULAR CHANGES AFTER RETINECTOMY FOR RETINAL DETACHMENT COMPLICATED BY PROLIFERATIVE VITREORETINOPATHY

PURPOSE

To report anatomical and functional outcomes of nonprimary retinectomy for rhegmatogenous retinal detachment with Grade C proliferative vitreoretinopathy, to assess the structural and functional macular changes in successful eyes.

METHODS

Retrospective single-center cohort study: one hundred-one consecutive retinectomies of 101 eyes affected by rhegmatogenous retinal detachment with C proliferative vitreoretinopathy between January 2014 and February 2020 were included.

RESULTS

The mean preoperative best-corrected visual acuity (BCVA) was 1.48 ± 0.71 logarithm of the minimal angle of resolution (20/604 Snellen equivalent). The anatomical success rate was 78.2% after one retinectomy and 83.1% after two retinectomies. The final BCVA ≥ 20/200 was achieved in 29% of cases, 8% gained ≥ 20/80. The final mean postoperative BCVA of successes with oil in situ was 1.68 ± 0.59 (20/957 Snellen equivalent) compared with 1.07 ± 0.63 logarithm of the minimal angle of resolution (20/235 Snellen equivalent) of successes after oil removal (P = 0.00005). Postoperative macular optical coherence tomography was obtained from 60/84 successes (71%). The normal macular profile was found in 3%, whereas majority demonstrated exudative maculopathy (51.5%), macular atrophy (22%), tractional maculopathy (21.5%), and macular disciform scar (2%). Bivariate linear relationship between final central foveal thickness and BCVA was statistically significant (P = 0.000013).

CONCLUSION

Satisfactory anatomical and functional outcome is possible after retinectomy for C proliferative vitreoretinopathy. Positive prognostic factors include the removal of oil without redetachment, normal macular status, and lower central foveal thickness. The functional outcome was influenced by macular changes, as final BCVA and central foveal thickness correlated.

Phenotype and Outcomes of Phakic Versus Pseudophakic Primary Rhegmatogenous Retinal Detachments: Cataract or Cataract Surgery Related?

PURPOSE

To compare phakic and pseudophakic primary rhegmatogenous retinal detachments (RD) and, within phakic RD, eyes with and without cataract.

DESIGN

Retrospective comparative clinical study.

METHODS

Setting: Online database of prospectively collected data. StudyPopulation: Patients aged ≥50 years who had undergone RD repair.

PROCEDURE

Data included baseline demographic and clinical features, surgical details, and anatomical and functional outcomes. Univariate analysis was performed to compare pseudophakic with phakic RD, and phakic RD with and without cataract. Age and sex dependency of variables was analyzed and the association of preoperative variables with final visual acuity was assessed using multivariate analysis. MainOutcomeMeasures: Preoperative features, intraoperative management, postoperative outcomes, association of preoperative features with postoperative outcomes.

RESULTS

Of 4,231 eyes, 1,212 were pseudophakic and 3,019 phakic, among which 310 had cataract. Pseudophakic RD showed significant differences compared with phakic RD, including older age, higher prevalence of male sex, foveal detachment, grade C proliferative vitreoretinopathy (PVR), inferior retinal breaks, inferior retinal involvement, and greater RD extent. Despite the more advanced features of pseudophakic RD, pseudophakia was a positive factor for visual outcome. Contralateral RD was more frequent in pseudophakic than phakic RD eyes (P < .0001). Within phakic RD, phakic RD with cataract exhibited several similarities with pseudophakic RD, including greater age, more frequent foveal detachment, PVR, and greater RD extent.

CONCLUSIONS

The presenting features differed significantly between pseudophakic and phakic RD, with greater occurrence of inferior retinal breaks and inferior retinal involvement in particular. Phakic RD with cataract shared several features in common with pseudophakic RD.

Paraneoplastic Granulomatous Vitritis: Elaboration of 8 Cases

PURPOSE

To describe the clinical features in a series of 8 patients with cytologically proven granulomatous vitritis in the context of systemic malignancy.

DESIGN

Retrospective case review series from 2004 through 2018 to identify all cases of cytologically proven granulomatous vitritis and to analyze its disease associations and causes.

PARTICIPANTS

Twenty-three patients with a cytologic diagnosis of granulomatous vitritis were identified, 8 of whom demonstrated systemic malignancy.

MAIN OUTCOME MEASURES

To identify a clinical profile of the 8 cases of granulomatous vitritis occurring in the setting of systemic malignancy, focusing on the timing of the eye presentation compared with the timing of the systemic malignancy.

METHODS

Patients with a cytologic diagnosis of granulomatous vitritis seeking treatment from 2004 through 2018 were included in this retrospective case series. Case notes were recalled and reviewed for demographic features, medical history, presenting symptoms, investigations, surgical procedures, and follow-up.

RESULTS

Twenty-three patients were diagnosed cytologically with granulomatous vitritis. Ten of 23 patients (43%) showed autoimmune and infectious causes, 5 of 23 patients (22%) showed were idiopathic causes, and 8 of 23 patients' (35%) disease was associated with systemic malignancy. In the latter group, the median age at presentation was 70 years (range, 55-89 years). Six patients showed bilateral disease, and the remaining 3 showed unilateral disease. Three of 8 patients showed primary systemic malignancy diagnosed after eye symptoms and 5 of 8 showed malignancy before the eye symptoms. These latter 5 patients all demonstrated a major relapse, metastasis, or both at the time of eye symptoms.

CONCLUSIONS

Paraneoplastic vitritis is primarily a disease of older age, with 67% of those affected older than 65 years. Ophthalmologists should maintain a high index of suspicion of paraneoplastic cause in bilateral posterior segment inflammation of uncertain origin, presenting for the first time, or heralding malignancy recurrence or metastasis in known cases of malignancy.

Impact of admission screening for methicillin-resistant Staphylococcus aureus on the length of stay in an emergency department

Preventing and controlling meticillin-resistant Staphylococcus aureus (MRSA) includes early detection and isolation. In the emergency department (ED), such measures have to be balanced with the requirement to treat patients urgently and transfer quickly to an acute hospital bed. We assessed, in a busy and overcrowded ED, the contribution made to a patient's stay by previous MRSA risk group identification and by selective rescreening of those patients who were previously documented in the research hospital as being MRSA positive. Patients with a previous diagnosis of MRSA colonisation were flagged automatically as ‘risk group’ (RG) on their arrival in the ED and were compared with ‘non-risk group’ (NRG), i.e. not previously demonstrated in the research hospital to be infected or colonised with MRSA. Over an 18 month period, there were 16 456 admissions via the ED, of which 985 (6%) were RG patients. The expected median times to be admitted following a request for a ward bed for NRG and RG patients were 10.4 and 12.9 h, respectively. Female sex, age >65 years, and RG status all independently predicted a statistically significantly longer stay in the ED following a request for a hospital bed. We consider that national and local policies for MRSA need to balance the welfare of patients in the ED with the need to comply with best practice, when there are inadequate ED and inpatient isolation facilities. Patients with MRSA requiring emergency admission must have a bed available for them.

The Transit/Admission Lounge study

In response to persistent overcrowding of Emergency Departments in Ireland, the Department of Health and Health Service Executive provided funding for "Transit Lounge" areas to be built. These lounges were to provide a location for patients to wait in beds pending the availability of a ward bed. This research was performed to assess the impact of such a lounge on the overcrowding of the Emergency Department and on patient outcomes. The time period from the opening of the Transit Lounge was compared with the same period a year earlier. The Transit Lounge delivers a comfortable place for patients to wait. It does not reduce Emergency Department overcrowding and has been associated with an increased time waiting for a ward bed. The solution to overcrowding is the creation of real capacity in the system so that ward beds are available in acute hospitals for the "unscheduled unwell".

Evaluation of formal feedback on endoscopic competence among trainees: the EFFECT trial

INTRODUCTION

The medical literature describes disparity in colonoscopy performance. This randomised, controlled study aimed to characterise the impact of feedback on colonoscopy performance among gastroenterology (GI) trainees.

METHODS

Gastroenterology trainees of similar experience levels who independently performed 581 colonoscopies over the study period were randomised to receive feedback/no feedback on their colonoscopy performance.

RESULTS

Baseline colonoscopy performance was similar in both groups. Following feedback, caecal intubation improved by 10.5% (from 72.9 to 83.4%, p = 0.04) in the feedback group and declined by 6.1% (from 78 to 71.9%, p = 0.2) in the control group; polyp detection improved by 5.1% (from 12.9 to 18.0%, p = 0.2) in the feedback group and by 2.9% (from 16.7 to 19.6%, p = 0.5) in the control group.

CONCLUSIONS

Systematic feedback appears to enhance colonoscopy performance among GI trainees.

Why are we waiting? A study of the patients' perspectives about their protracted stays in an emergency department

The overcrowding of Emergency Departments compromises their critical function and the safety of patients and staff. This study asked the patients how the wait in overcrowded conditions impacted on them and the care they received and what they believed the reasons for the overcrowding were. A prospective questionnaire based structured interview study was performed. Over half (57.7%) of patients felt that the lack of inpatient beds and wards was the main reason that they experienced delays. An overwhelming 85.9% felt that the Health Authorities were not doing enough to address the overcrowding issue. Overcrowding of Emergency Departments has been identified as a major problem the solution is to be found in increasing the capacity of the acute hospital system according to the majority of our study population.

Visually significant persistent outer retinal fluid following closure of a macular hole

PURPOSE

We report two cases of persistent outer retinal fluid defects following macular hole surgery.

METHODS

Twenty-eight consecutive patients who underwent macular hole surgery performed by a single surgeon were examined pre- and postoperatively using slit-lamp biomicroscopy and optical coherence tomography (OCT).

RESULTS

Two patients from this series were identified by OCT as having persistent outer retinal fluid defects after macular hole surgery, despite closure of the holes on biomicroscopy. One patient had only a small defect present at 6 weeks, with very good visual improvement, which was later shown to have resolved. The second had a large persistent defect and no postoperative improvement in vision despite the eventual resolution of the fluid 17 months later.

CONCLUSIONS

Large pockets of persistent outer retinal fluid defects as shown on OCT may reduce final visual acuity in patients following macular hole surgery.

A prospective, case controlled study of the natural history of diabetic retinopathy and maculopathy after uncomplicated phacoemulsification cataract surgery in patients with type 2 diabetes

AIM

To determine if uncomplicated phacoemulsification cataract surgery is associated with an accelerated rate of progression of diabetic retinopathy or maculopathy postoperatively.

METHODS

A prospective trial of 50 type 2 diabetics undergoing monocular phacoemulsification cataract surgery by a single consultant surgeon. The grade of diabetic retinopathy and diabetic maculopathy in the operated and non-operated fellow eye was assessed preoperatively and for 12 months postoperatively.

RESULTS

Overall, retinopathy progression was observed in 11 patients. In seven the retinopathy progressed in both eyes, in three it progressed in the operated eye alone, and in one it progressed in the fellow eye alone. Macular oedema was observed in 13 eyes postoperatively. Four had transient pseudophakic cystoid macular oedema and nine true diabetic maculopathy. Where maculopathy progressed it did so symmetrically in five patients, it progressed in the operated eye alone in four patients, and the fellow eye alone in two patients. There was no significant difference in the number of operated and fellow eyes whose retinopathy or maculopathy progressed postoperatively. In both the operated (OE) and non-operated (NoE) eyes retinopathy progression was associated with a higher mean HbA(1)C (OE p=0.003; NoE p=0.001) and insulin treatment (OE p=0.008, NoE p=0.04).

CONCLUSION

Uncomplicated phacoemulsification cataract surgery does not cause acceleration of diabetic retinopathy postoperatively and any progression that is observed probably represents the natural history of the disease. Although macular oedema is common after cataract surgery it may follow a benign course and in many patients the development of clinically significant macular oedema postoperatively probably represents natural disease progression rather than being a direct effect of surgery.

Ultrasonic localization of anesthetic fluid in sub-Tenon's, peribulbar, and retrobulbar techniques

PURPOSE

To determine the distribution of anesthetic fluid during 3 regional anesthetic techniques routinely used for phacoemulsification.

METHODS

Patients having routine cataract extraction by phacoemulsification were studied after informed consent had been obtained. B-scan ultrasonography was performed on the eye before administration of the anesthetic agent. Kinetic echography was used to scan the eye during administration of the anesthesia to show the needle position and location of fluid in the orbit during the injection. Ten minutes after injection, another scan was performed to outline the pattern of fluid distribution.

RESULTS

In all patients, the needle and the anesthetic fluid were seen on ultrasonography, with sub-Tenon's the most easily seen. In the sub-Tenon's group, fluid tracked behind the globe in the retrobulbar space, appearing as a dark outline during the injection. The fluid around the optic nerve developed a characteristic T sign. In the retrobulbar technique, the needle was less easily identifiable and fluid localized within the cone. The fluid distributed in the intraconal fat. Identification of the peribulbar needle and fluid was also more difficult; the fluid was, however, seen in the extraconal fat. After 10 minutes, fluid was seen within the cone.

CONCLUSION

B-scan ultrasonography was a suitable method of identifying the needle position and the distribution of anesthetic fluid in regional ocular anesthesia. The sub-Tenon's technique appears to be the safest method of introducing anesthetic fluid into the retrobulbar space without the potential complications of sharp-needle techniques.

Ultrasonography of the optic disc cup in discs of various sizes

PURPOSE

The aim of the study was to evaluate the sensitivity of modern, eye-medicated B-scanners in detecting optic disc cups and to correlate the echographic measurements with an optical assessment. A secondary aim was to correlate the rim-to-rim diameter of the optic disc and the width of the retrobulbar optic nerve on standardised A-scan.

METHODS

A prospective study was conducted on 25 emmetropic subjects (50 eyes) with discs and cups of various sizes. They were examined optically by one observer using a high-magnification slit lamp and the 90 D Volk lens. Another observer measured the B-scan dimensions of the disc cups and the retrobulbar optic nerve. Data from the two observers were compared at the end of the study.

RESULTS

High resolution B-scan detected optic disc cups of 0.5 mm or larger in all cases. A statistically significant correlation was obtained between echographic measurements and both vertical optical cup disc diameters and cup disc (C:D) ratios (p < 0.0001). Large C:D ratios (0.6 or larger) but small rim-to-rim disc diameter were reported as 'small' on echography. No correlation was found between the measurement of retrobulbar nerve and the diameter of the vertical optical disc diameter.

CONCLUSION

Modern, eye-dedicated ultrasonographic scanners are capable of detecting optic disc cups of 0.5 mm or larger. As there is a normal variation in optic disc rim-to-rim diameter, and this cannot be measured using ultrasound, we suggest the reporting of a C:D ratio on the ultrasonography to be potentially misleading. Large disc cups are, however, easily seen and many are likely to be 'pathological'.

Intracellular translocation of endothelial nitric oxide synthase by lysophosphatidylcholine

The amphiphile lysophosphatidylcholine (LPC) modulates the activity of membrane-associated enzymes such as phospholipase A2, adenylate and guanylate cyclases and ATPase. LPC also relaxes vascular smooth muscle through production of nitric oxide. On the basis of reports that bradykinin translocates nitric oxide synthase (NOS) from the membrane to the cytosol, we investigated whether a similar translocation occurs with LPC. It was found that LPC translocated NOS from the membrane to the cytosolic fraction. Total NOS activity remained at the control level.

Inducible nitric oxide synthase activity in myocardium after myocardial infarction in rabbit

The activity of nitric oxide synthase (NOS) in infarcted and noninfarcted rabbit myocardium was determined. NOS activity, as measured by conversion of [14C]arginine to [14C]citrulline, was significantly higher in the infarcted area of myocardium (22.7 +/- 3.7 fmol/mg as compared to 7.67 +/- 1.0 in noninfarcted area). NOS activity within the area of risk remained on control level. Increased inducible NOS activity was observed on the first postoperative day and persisted for at least 14 days; it declined 3 weeks after infarction. Citrulline formation was inhibited by N-omega-nitro-L-arginine and N-omega-monomethyl-L-arginine The localization of NOS by monoclonal anti-NOS antibody indicates mononuclear cells/macrophages as the likely source of the enzyme. The concentrations of tumor necrosis factor-alpha and interleukin-1 beta were not increased in peripheral blood or myocardium.

Bilateral orbital metastases from transitional cell carcinoma of the bladder

A case of bilateral orbital metastases arising from a primary transitional cell carcinoma of the bladder is presented, with simultaneous presentation of both primary and metastatic disease. The literature is reviewed.

Influence of selective phosphodiesterase inhibitors on human neutrophil functions and levels of cAMP and Cai

Chromatographic analysis of 3',5'-cyclic nucleotide phosphodiesterase (PDE) isoenzymes in the cytosol of human neutrophils shows the predominant presence of PDE IV (cAMP specific) and PDE V (cGMP specific). PDE IV is characterized by (1) cAMP selectivity, (2) a KM for cAMP of 1.2 microM and (3) a typical rank order of IC50-values for PDE inhibitors: 0.13, 0.17, 47 and 9.5 microM for PDE IV selective rolipram, PDE III/IV selective zardaverine, PDE III selective motapizone and unselective 3-isobutyl-1-methylxanthine (IBMX), respectively. Functions of polymorphonuclear leukocytes (PMN) such as N-formylmethionyl-leucyl-phenylalanine (fMLP)-stimulated superoxide release and fMLP/thimerosal elicited leukotriene (LT) biosynthesis are inhibited by these PDE inhibitors with the same rank order and even lower IC50-values. Measurements of changes in cytosolic Cai in Fura-2 loaded PMN demonstrate a transient Cai increase after stimulation with 0.1 microM fMLP and an additional sustained elevation of Cai levels in the presence of thimerosal. PDE inhibitors suppress this sustained phase of Cai release with the same rank order of IC50-values as LT biosynthesis. The correlation between fMLP/thimerosal-induced LT biosynthesis and Cai levels reveal a Cai threshold of 150 nM for arachidonic acid metabolism. cAMP levels in PMN were elevated by PDE inhibitors alone by less than 2-fold. In the presence of fMLP however, cAMP was increased up to 10-fold and the efficacy of PDE inhibitors to increase cAMP paralleled their potency to inhibit PDE IV.(ABSTRACT TRUNCATED AT 250 WORDS)

Zardaverine as a selective inhibitor of phosphodiesterase isozymes

The pyridazinone derivative zardaverine has recently been introduced as a potent bronchodilator in vivo and in vitro. In addition, zardaverine exerts a positive inotropic action on heart muscle in vitro. The actions of zardaverine are thought to be mediated via inhibition of phosphodiesterase (PDE) activity. Recent data suggest that there are multiple forms of phosphodiesterases and at least five different isozyme families are now recognized. In the present study, the effects of zardaverine on the different PDE isozymes were investigated in several tissues. PDE isozymes were separated by chromatography on Q-sepharose. Zardaverine inhibited the cyclic GMP-inhibitable PDE III from human platelets and the rolipram-inhibitable PDE IV from canine trachea and human polymorphonuclear (PMN) cells with IC50-values of 0.58, 0.79 and 0.17 microM, respectively. The pyridazinone derivative affected the calmodulin-stimulated PDE I, the cyclic GMP-stimulated PDE II and the cyclic GMP-specific PDE V only marginally at concentrations up to 100 microM. Zardaverine inhibits the ADP-induced aggregation of human platelets with an IC50 of 1.6 microM. This inhibition was synergistically increased by activators of adenylate cyclase such as PGE1 and forskolin. In human PMN cells, zardaverine inhibited the zymosan-induced superoxide anion generation with an IC50 of 0.40 microM. Again, this effect was increased by activators of adenylate cyclase. These data clearly demonstrate that zardaverine is a selective inhibitor of PDE III and PDE IV isozymes.