Midperipheral mini-capsulorhexis as an additional step for safe phacoemulsification in white intumescent cataracts

ABSTRACT

The present article describes a novel surgical technique of a primary mini-capsulorhexis in midperiphery to minimize surgical complications in white intumescent cataracts. Patients with white mature cataracts with a convex anterior capsule or swollen lens fibers were selected. An initial puncture was made 3-4 mm away from the center, in the midperipheral anterior capsule, with a conventional cystitome. A mini-capsulorhexis (2-2.5 mm) was created. Loose cortical matter and fluidic contents were aspirated to reduce the intralenticular pressure. Two cuts were made at the margin of the mini-capsulorhexis, and an adequately sized secondary rhexis was completed, after which phacoemulsification was done. A circular curvilinear capsulorhexis was successfully achieved in all cases, including those with a small pupil. Rhexis could be completed in a patient where an initial extension occurred due to head movement. This refined technique aims to enhance the safety and precision of capsulorhexis in intumescent cataracts, thereby reducing the risk of complications such as the Argentinian flag sign. Further exploration and validation of this approach through clinical trials are warranted to establish its efficacy and safety profile.

COVID-19 detection in lung CT slices using Brownian-butterfly-algorithm optimized lightweight deep features

Several deep-learning assisted disease assessment schemes (DAS) have been proposed to enhance accurate detection of COVID-19, a critical medical emergency, through the analysis of clinical data. Lung imaging, particularly from CT scans, plays a pivotal role in identifying and assessing the severity of COVID-19 infections. Existing automated methods leveraging deep learning contribute significantly to reducing the diagnostic burden associated with this process. This research aims in developing a simple DAS for COVID-19 detection using the pre-trained lightweight deep learning methods (LDMs) applied to lung CT slices. The use of LDMs contributes to a less complex yet highly accurate detection system. The key stages of the developed DAS include image collection and initial processing using Shannon's thresholding, deep-feature mining supported by LDMs, feature optimization utilizing the Brownian Butterfly Algorithm (BBA), and binary classification through three-fold cross-validation. The performance evaluation of the proposed scheme involves assessing individual, fused, and ensemble features. The investigation reveals that the developed DAS achieves a detection accuracy of 93.80% with individual features, 96% accuracy with fused features, and an impressive 99.10% accuracy with ensemble features. These outcomes affirm the effectiveness of the proposed scheme in significantly enhancing COVID-19 detection accuracy in the chosen lung CT database.

Outcomes of topography-guided PRK/CXL in keratoconus using the NIDEK CXIII system-"Bharat Protocol" (Pilot study)

Purpose

Outcome of topography-guided excimer laser ablation in conjunction with accelerated, high-fluence cross-linking in corneal ecstatic disease using the NIDEK CXIII equipped with CATz algorithm from the FinalFit software-"Bharat Protocol."

Methods

Retrospective case record review of 30 eyes of 17 patients of stage 1-3 keratoconus who underwent the procedure was performed. Data collected were for visual acuity, distortion-induced eye pain, and keratometry. Pachymetry, lower order and higher order aberrations, spherical aberrations, and topographic cylinder were documented from by Scheimpflug imaging (Pentacam 70700: Oculus, Wetzlar, Germany).

Results

At a minimum follow-up of 6 months (range 6.2-13 months), there was significant improvement in UCVA (P < 0.00001), BCVA (P = 0.0061), decrease in Kmax (P = 0.0349), Ksteep (P < 0.0411), Kflat (P = 0.0099), and pachymetry (P = 0.0001). Significant improvement was also seen in distortion-induced eye pain (27/30 to 2/30; P < 0.00001). A more than two-line improvement in UCVA and BCVA was seen in 23/30 and 17/30 cases, respectively. Ectasia was stabilized in all cases at the last follow-up, and no complications were seen.

Conclusions

The "Bharat" Protocol to arrest keratectasia progression and improve corneal regularity is a safe and efficacious alternative as a keratoconus management option. This is the first such study on Nidek Platform for the same.

Glauco-Claw: A novice implant for chronic angle-closure glaucoma

This article describes 1-year outcomes of a new intra-ocular implant, "Glauco-Claw," in refractory chronic angle-closure glaucoma (ACG). Glauco-Claw is a novice polymethylmethacrylate implant with a central ring and five claws placed circumferentially. It was placed in the anterior chamber and the peripheral iris was tucked into the claws, thus causing goniosynechialysis and preventing the reformation of goniosynechiae. It was implanted in five eyes of five patients, and they were followed up for 1 year. Target intra-ocular pressure was achieved and maintained in all the patients till the last follow-up. Two patients did not require any anti-glaucoma medication. No significant complications were observed in any patient. Glauco-Claw could be another armamentarium in the management of refractory chronic ACG.

Customized Bowman-Stromal Inlay: An Attempt to Change the Topography of the Keratoconus Cornea

PURPOSE

The objective of this report is to describe a modification of a previously reported technique with an aim of improving the corneal topography and visual outcomes in progressive keratoconus along with stabilization of ectasia.

METHOD

In a 26-year-old man with progressive keratoconus, corneal collagen cross-linking was performed in one eye. The other eye had a keratometry of 69.6 D and thinnest pachymetry of 397 µm for which a customized Bowman-stromal inlay surgery was performed. The technique involved the harvesting of Bowman-stromal inlay (anterior 180-μm human donor cornea having the Bowman's layer and anterior stroma) using the femtosecond laser and central ablation of this inlay was done on the stromal side using an excimer laser. This customized inlay was placed in the anterior stromal pocket of the patient's cornea using a regular intraocular lens injector.

RESULTS

Stabilization of keratoconus could be achieved in the present case along with improvement in the corrected distance visual acuity and pachymetry. Maximum keratometry decreased from 69.6 D to 57.3 D.

CONCLUSIONS

Customized Bowman-stromal inlay technique appears to be a step towards creating an ideal inlay for the keratoconus cornea.

Novel custom designed toric piggyback intraocular lens for the correction of residual postoperative astigmatism

We report the outcomes of a custom-designed toric piggyback intraocular lens in a patient with high postoperative residual astigmatism. A 60-year-old male patient underwent customized toric piggyback IOL for postoperative residual astigmatism of 13 D, with follow-up examinations for IOL stability and refractive outcomes. The refractive error stabilized at two months and remained stable at one year, with a correction of nearly 9 D of astigmatism. The IOP remained within normal limits, and there were no postoperative complications. The IOL remained stable in the horizontal position. To our knowledge, this is the first case report of correction of unusually high astigmatism by a novel smart toric design of piggyback IOL.

An intuitionistic approach for the predictability of anti-angiogenic inhibitors in cancer diagnosis

Malignant cancer angiogenesis has historically attracted enormous scientific attention. Although angiogenesis is requisite for a child's development and conducive to tissue homeostasis, it is deleterious when cancer lurks. Today, anti-angiogenic biomolecular receptor tyrosine kinase inhibitors (RTKIs) to target angiogenesis have been prolific in treating various carcinomas. Angiogenesis is a pivotal component in malignant transformation, oncogenesis, and metastasis that can be activated by a multiplicity of factors (e.g., VEGF (Vascular endothelial growth factor), (FGF) Fibroblast growth factor, (PDGF) Platelet-derived growth factor and others). The advent of RTKIs, which primarily target members of the VEGFR (VEGF Receptor) family of angiogenic receptors has greatly ameliorated the outlook for some cancer forms, including hepatocellular carcinoma, malignant tumors, and gastrointestinal carcinoma. Cancer therapeutics have evolved steadily with active metabolites and strong multi-targeted RTK inhibitors such as E7080, CHIR-258, SU 5402, etc. This research intends to determine the efficacious anti-angiogenesis inhibitors and rank them by using the Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE- II) decision-making algorithm. The PROMETHEE-II approach assesses the influence of growth factors (GFs) in relation to the anti-angiogenesis inhibitors. Due to their capacity to cope with the frequently present vagueness while ranking alternatives, fuzzy models constitute the most suitable tools for producing results for analyzing qualitative information. This research's quantitative methodology focuses on ranking the inhibitors according to their significance concerning criteria. The evaluation findings indicate the most efficacious and idle alternative for inhibiting angiogenesis in cancer.

Surgical application of Ong speculum in simple limbal epithelial transplantation and pterygium surgery

Ong speculum is used in glaucoma surgeries such as trabeculectomy to expose the superior part of the globe. The large inferior blade pushes the inferior conjunctival fornix, due to which the eyeball rotates downwards. It has not been used in other anterior segment surgeries before. We used this speculum in simple limbal epithelial transplantation (SLET) and pterygium surgery to expose superior bulbar conjunctiva for harvesting limbal and conjunctival grafts, respectively. As the superior conjunctiva and sclera become exposed, it facilitates the steps of harvesting limbal biopsy and conjunctival graft in SLET and pterygium surgery. This eliminated the need for a superior rectus suture or an assistant who would keep the globe rotated downwards. Its position could also be maneuvered to adjust the site of exposure when dissecting the area of pannus in SLET. Thus, it makes the superior conjunctiva more accessible.

Descemet membrane endothelial keratoplasty (DMEK) aquarium: Diving in to learn DMEK surgical concepts

A novel simulation model (without using human corneas) has been described for understanding the surgical concepts and developing tactile reflexes of Descemet membrane (DM) endothelium scroll manipulation and orientation in the anterior chamber, which are necessary for performing Descemet membrane endothelial keratoplasty (DMEK). Termed the "DMEK aquarium," this model helps facilitate the understanding of different maneuvers of the DM graft needed inside the fluid-filled anterior chamber, like unrolling or unfolding, flipping or inversion, and checking orientation and centration in the host cornea. A stepwise plan for surgeons starting to learn DMEK utilizing various available resources is also suggested.

Multimodal analysis of the COVID-19-associated mucormycosis outbreak in Delhi, India indicates the convergence of clinical and environmental risk factors

BACKGROUND

The aetiology of the major outbreak of COVID-19-associated mucormycosis (CAM) in India in spring 2021 remains incompletely understood. Herein, we provide a multifaceted and multi-institutional analysis of clinical, pathogen-related, environmental and healthcare-related factors during CAM outbreak in the metropolitan New Delhi area.

METHODS

We reviewed medical records of all patients diagnosed with biopsy-proven CAM (n = 50) at 7 hospitals in the New Delhi, and NCR area in April-June 2021. Two multivariate logistic regression models were used to compare clinical characteristics of CAM cases with COVID-19-hospitalised contemporary patients as controls (n = 69). Additionally, meteorological parameters and mould spore concentrations in outdoor air were analysed. Selected hospital fomites were cultured. Mucorales isolates from CAM patients were analysed by ITS sequencing and whole-genome sequencing (WGS).

RESULTS

Independent risk factors for CAM identified by multivariate analysis were previously or newly diagnosed diabetes mellitus, active cancer and severe COVID-19 infection. Supplemental oxygen, remdesivir therapy and ICU admission for COVID-19 were associated with reduced CAM risk. The CAM incidence peak was preceded by an uptick in environmental spore concentrations in the preceding 3-4 weeks that correlated with increasing temperature, high evaporation and decreasing relative humidity. Rhizopus was the most common genus isolated, but we also identified two cases of the uncommon Mucorales, Lichtheimia ornata. WGS found no clonal population of patient isolates. No Mucorales were cultured from hospital fomites.

CONCLUSIONS

An intersection of host and environmental factors contributed to the emergence of CAM. Surrogates of access to advanced COVID-19 treatment were associated with lower CAM risk.

Partial-thickness compression sutures without descemetopexy for management of acute hydrops in keratoconus: A novel surgical technique

This article reports a novel surgical technique of partial-thickness compression sutures without descemetopexy with air or gas for the management of acute hydrops in keratoconus. Two patients presented with localized corneal edema with a Descemet membrane (DM) tear in the left eye. Tomography of the right eye revealed localized steepening with increased maximum keratometry and decreased central pachymetry. They were diagnosed with keratoconus in the right eye and acute corneal hydrops (ACH) in the left eye. Compression sutures were passed through the stroma without touching the DM. The anterior chamber was not entered at all at any point during the surgery. Resolution of edema was noted intraoperatively itself. Further resolution of edema was noted from the first postoperative day which markedly reduced within the first week. A corneal scar with no edema was seen at six weeks. In both the patients, vision at presentation was counting fingers close to face which improved to 20/60 and 20/50, respectively, at the last visit.

465. A Multifaceted and Multi-Institutional Analysis of the COVID19-Associated Mucormycosis Outbreak in the Delhi Area Indicates the Simultaneous Convergence of Multiple Risk Factors

Background

A major outbreak of COVID19-associated mucormycosis (CAM) in India in spring 2021 aggravated the death toll of COVID19. As the causes of that CAM outbreak remain unclear, we performed a multifaceted study of host, pathogen, environmental, and heath care-related factors in adult CAM patients (pts) in the metropolitan New Delhi area.

Methods

We reviewed the records of all pts diagnosed with culture- or biopsy-proven CAM at 7 hospitals in the New Delhi area (April 1 – June 30, 2021). We used a multivariate logistic regression model to compare clinical characteristics of either all CAM cases (analysis 1, n = 50) or only pts with CAM after moderate or severe COVID19 (analysis 2, n = 31). As controls for both analyses, we used 69 COVID19-hospitalized contemporary pts. Selected hospital fomites were cultured for Mucorales. Additionally, we compared meteorological data and fungal spore concentrations in outdoor air before the CAM outbreak (January-March 2021) and during the outbreak (April-June 2021). Mucorales isolates from CAM pts were identified by MALDI-TOF-MS and ITS sequencing. A subset of 15 isolates underwent whole genome sequencing (WGS).

Results

Risk factors for CAM in both analyses were newly diagnosed diabetes mellitus (odds ratio [OR] 8.26/5.67) and active cancer (OR 5.98/5.68) (Figure 1). Supplemental oxygen for COVID19 was associated with a lower CAM risk in both analyses (OR 0.13/0.17). Another significant CAM risk predictor identified only in analysis 1 was severe COVID19 (WHO score ≥ 6, OR 4.09), while remdesivir therapy (OR 0.40) and ICU admission for COVID19 were protective (OR 0.41) (Figure 1). No Mucorales were cultured from hospital fomites. The CAM incidence peak coincided with a significant uptick in environmental spore concentrations but was not linked to specific meteorological factors. Rhizopus was the predominant Mucorales genus (64%) identified by MALDI-TOF-MS and ITS sequencing; WGS found no clonal population of isolates but detected 2 cases of the rare pathogen Lichtheimia ornata. Figure 1

Conclusion

An intersection of host, environmental, pathogen and healthcare-related factors might have contributed to the emergence of CAM. Surrogates of access to advanced treatment of COVID19 were associated with lower CAM risk.

Disclosures

Dimiitrios P. Kontoyiannis, MD, ScD, PhD (hon), AbbVie: Advisor/Consultant|Astellas Pharma: Advisor/Consultant|Astellas Pharma: Grant/Research Support|Astellas Pharma: Honoraria|Cidara Therapeutics: Advisor/Consultant|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|Gilead Sciences: Honoraria|Merck: Advisor/Consultant.

Novel Application of Predictive Modeling: A Tailored Approach to Promoting HCC Surveillance in Patients With Cirrhosis

OBJECTIVE

There has been increased interest in interventions to promote hepatocellular carcinoma (HCC) surveillance given low utilization and high proportions of late stage detection. Accurate prediction of patients likely versus unlikely to respond to interventions could allow a cost-effective approach to outreach and facilitate targeting more intensive interventions to likely non-responders.

DESIGN

We conducted a secondary analysis of a randomized clinical trial evaluating a mailed outreach strategy to promote HCC surveillance among 1200 cirrhosis patients at a safety-net health system between December 2014 and March 2017. We developed regularized logistic regression (RLR) and gradient boosting machine (GBM) algorithm models to predict surveillance completion during each of the 3 screening rounds in a training set (n = 960). Model performance was assessed using multiple performance metrics in an independent test set (n = 240).

RESULTS

Among 1200 patients, surveillance was completed in 41-47% of patients over the three rounds. The RLR and GBM models demonstrated good discriminatory accuracy, with area under receiver operating characteristic (AUROC) curves of 0.67 and 0.66 respectively in the first surveillance round and improved to 0.77 by the third surveillance round after incorporating prior screening behavior as a feature. Additional performance characteristics including the Brier score, Hosmer-Lemeshow test and reliability diagrams were also evaluated. The most important variables for the predictive model were prior screening completion status and past primary care contact.

CONCLUSIONS

Predictive models can help stratify patients' likelihood to respond to surveillance outreach invitations, facilitating tailored strategies to maximize effectiveness and cost-effectiveness of HCC surveillance population health programs.

Silver-sepiolite (Ag-Sep) hybrid reinforced active gelatin/date waste extract (DSWE) blend composite films for food packaging application

In this study, date syrup waste extract (DSWE) (15 wt%) and different content of silver doped sepiolite hybrid (Ag-Sep, 0.25-3 wt%) were incorporated into gelatin matrix to develop a series of active composite packaging films. Incorporating 2 wt% of Ag-Sep increased the modulus of blend film by 98% compared to unmodified gelatin/DSWE blend film. The active gelatin composite film exhibited superior active compounds migration to aqueous food simulants. Besides, Ag-Sep provided a tortuous pathway to the composite film, resulting in high 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical inhibition efficiency (91%) and slow-release kinetics of active compounds to the food simulant. The Ag-Sep hybrid was improved the antimicrobial property of the gelatin/DSWE blend film against both gram-negative and gram-positive microbes. Thus, this study demonstrated that the Ag-Sep hybrid exhibits significant properties in the active gelatin composite films, implying that this hybrid could be an effective additive for various active packaging films.

Bowman-stromal inlay using an intraocular lens injector for management of keratoconus

A simple approach for transplanting Bowman layer and anterior stroma Bowman-stromal inlay (BSI) in keratoconic patients as an intervention to cease progression of ectasia and increase the overall thickness is described. A femtosecond laser was used to create BSI from human eye bank donor corneas and form an intrastromal pocket in the host cornea. The inlay was placed in the intrastromal space using an intraocular lens injector. This technique was performed successfully in 10 eyes of patients with progressive corneal ectasia. Postoperatively, the increased host pachymetry was as per BSI thickness. The tomography parameters remained stable, suggesting stabilization of keratoconus over a mean 15.9 months of follow-up. The BSI may offer a technically easy and safe technique of stromal augmentation to arrest keratoconus progression. It also opens up the possibility of surface ablation in the future for visual rehabilitation.

Fabrication of High Dielectric Materials Through Selective Insertion of Functionalized Reduced Graphene Oxide on Hard Segment of Thermoplastic Polyurethane

The presence of microcapacitors near percolatrion threshold determines dielectric permittivity of a material. Motivated by this concept, we focused our work by preferentially allocating functionalized reduced graphene oxide (FRGO) in hard segment (disperse phase) of Thermoplastic polyurethane (TPU) by solution blending method and characterized. Morphological studies of TPU/FRGO nanocomposites established homogeneous dispersion of FRGO throughout the TPU matrix. It is noted that TPU/FRGO (1 phr) nanocomposites exhibit maximum increase in tensile strength (33%) and elongation at break (10%). Thermogravimetric analysis (TGA) showed maximum enhancement in onset of decomposition temperature (~6 °C) in 2 phr FRGO loaded TPU. Differential scanning calorimetry (DSC) analysis showed maximum reduction (~2 °C) in glass transition temperature (T_g) of soft segment of TPU followed by maximum improvements in melting temperature (~4 °C) as well as crystallization temperature (~22 °C) of hard segment compared to neat TPU. Further, a significantly high value of dielectric permittivity (401) is achieved in 1.5 phr loaded FRGO at 100 Hz due to the formation of significantly higher number of microcapacitors near the percolation threshold. It is anticipated that such thermally stable and mechanically strong high dielectric TPU/FRGO nanocomposites can find applications in the field of electronic devices.

Deep Learning Approach for Voice Pathology Detection and Classification

A non-invasive cum robust voice pathology detection and classification architecture is proposed in the current manuscript. In place of the conventional feature-based machine learning techniques, a new architecture is proposed herein which initially performs deep learning-based filtering of the input voice signal, followed by a decision-level fusion of deep learning and a non-parametric learner. The efficacy of the proposed technique is verified by performing a comparative study with very recent work on the same dataset but based on different training algorithms.The proposed architecture has five different stages.The results are recorded in terms of nine (9) different classification score indices which are – mean average Precision, sensitivity, specificity, F1 score, accuracy, error, false-positive rate, Matthews Correlation Coefficient, and the Cohen’s Kappa index. The experimental results have shown that the use of machine learning classifier can get at most 96.12% accuracy, while the proposed technique achieved the highest accuracy of 99.14% in comparison to other techniques.

Classification of Parkinson Disease Based on Analysis and Synthesis of Voice Signal

The most important application of voice profiling is pathological voice detection. Parkinson's disease is a chronic neurological degenerative disease affecting the central nervous system responsible for essentially progressive evolution movement disorders. 70% to 90% of Parkinson’s disease (PD) patients show an affected voice. This paper proposes a methodology for PD based on acoustic, glottal, physical, and electrical parameters. The results show that the acoustic parameter is more important in the case of Parkinson’s disease as compared to glottal and physical parameters. The authors achieved 97.2% accuracy to differentiate Parkinson and healthy voice using jitter to pitch ratio proposed algorithm. The Authors also proposed an algorithm of poles calculation of the vocal tract to find formants of the vocal tract. Further, formants are used for finding the transfer function of vocal tract filter. In the end, the authors suggested parameters of the electrical vocal tract model are also changed in the case of PD voices.

Vocal Folds Analysis for Detection and Classification of Voice Disorder

The detection and description of pathological voice are the most important applications of voice profiling. Currently, techniques like laryngostroboscopy or surgical microlarynoscopy are popularly used for the diagnosis of voice pathologies but are invasive in nature. Disorders of vocal folds impact the quality of voice, and therefore, the accuracy of voice profiling is reduced. This paper presents a better solution to differentiate normal and pathological voices based on the glottal, physical, and acoustic and equivalent electrical parameters. These parameters have been correlated using mathematical equations and models. Results reveal that the glottal flow is strongly influenced by physical parameters like stiffness and viscosity of vocal folds in case of pathological voice. However, their direct measurement requires complex invasive medical procedures or costly and complex electronic hardware arrangements in case of non-invasive methods. Glottal parameters, on the other hand, facilitate much simpler estimation of vocal folds disorders. In this work, the authors have presented two non-invasive approaches for better accuracy and least complexity for differentiating normal and pathological voices: 1) by using correlation of glottal and physical parameters, 2)by using acoustic and equivalent electrical parameters.

Effect of date fruit waste extract as an antioxidant additive on the properties of active gelatin films

In this work, date-fruit syrup waste extract (DSWE) was used as an antioxidant additive to develop active gelatin films with enhanced food preservation properties. The effect of DSWE content (5, 10, 15, and 25 wt%) on the mechanical, physical, and antioxidant properties of the gelatin films were analyzed. Total phenolic content and antioxidant assay analysis revealed that the active compounds in blend films are highly migrated to the aqueous phase than the fatty medium. In the canola oil stability studies, gelatin/25 wt% DSWE film immersed oil sample exhibited low peroxide (POV) and p-anisidine (PV) values of 28.6 and 7.1, respectively, compared to the control oil (POV = 41.7 and PV = 13.1) in the air atmosphere and 45 °C for 30 days. Totox values of canola oil samples were decreased as a function of DSWE content in the films, indicating that polyphenols in DSWE are significantly resistant to oil's lipid oxidation.

UV Aging Behavior of Functionalized Mullite Nanofiber-Reinforced Polypropylene

In this study, the effect of accelerated ultraviolet (UV) aging on the properties of polypropylene (PP) as well as its blend with PP-graft-maleic anhydride (PP-g-MA) and composite with amine-functionalized mullite nanofibers (AMNF) was compared. Solid-state NMR exhibited some changes in the macromolecular chain structure after aging, whereas the formation of degradation products was confirmed through Fourier transform infrared (FTIR) spectroscopy. The aged composite was observed to exhibit the least increment in the crystallinity from X-ray and differential scanning calorimetry (DSC) analyses (0.3 and 0.5%, compared to 9.7 and 10.4%, respectively, for PP) owing to the stability of its amorphous phase against degradation. Similar resistance toward degradation was also confirmed by thermogravimetric analysis (TGA). The surface morphology of the materials also exhibited the lowest extent of surface embrittlement as well as a small number of shallow cracks in the case of a-PP/PP-g-MA/AMNF composite. The aged composite had a much higher impact strength of 14.9 kJ m-2 compared to 2.5 kJ m-2 for aged PP, thus exhibiting its stability against degradation owing to a synergistic combination of the filler and compatibilizer. The optimal performance of the composite was further confirmed through the least extent of reduction in the tensile strength and elongation at break. These findings demonstrate the superior performance of AMNF-reinforced PP composite over PP for outdoor applications.

Immunohistological Study of Palpebral Lobe of the Lacrimal Gland in Severe Dry Eyes Secondary to Stevens-Johnson Syndrome

PURPOSE

To detect the immunohistochemical changes in the main lacrimal glands of patients suffering from chronic ocular sequelae of Stevens-Johnson syndrome (SJS).

METHODS

Histological sections of biopsies from the lacrimal gland of three chronic SJS patients (mean age, 33 years; 2 males) with severe dry eye disease (Schirmer = 0 mm) were assessed using double immunofluorescence techniques. Changes in the expression of secretory proteins lactoferrin (Lf), lysozyme (Ly), aquaporin 5 (AQP5), S-100, and early apoptosis marker (Annexin V) were studied.

RESULTS

Different morphological expressions of secretory proteins were present in the three samples. One sample had maintained the immunoreactivity for Lf, Ly, S-100, similar to healthy controls. Two samples had significantly reduced immunoreactivity for anti-Lf, anti-Ly, and S-100, the weakest being in the sample with distorted lobular architecture and mild interlobular fibrosis. AQP5 had a distinct vesicular intracytoplasmic immunoreactivity suggesting defective trafficking and integration of the protein to the apical membrane. There was no S-100 immunostaining in the acinar or ductal epithelium, whereas interstitial nerve fibers scattered in the periacinar region showed reduced immunoreactivity for S-100. There was strong Annexin V immunoreactivity in the nuclei of epithelial cells in the majority of acinar and ductal epithelia of all the samples, with distorted nuclear morphology in one sample.

CONCLUSION

Defective trafficking of AQP5 and variable expression of Ly, Lf, S-100 are the notable findings in the lacrimal glands of chronic SJS patients along with signs of early apoptosis. It suggests that the palpebral lobe of the lacrimal gland is involved in the pathological processes occurring in the conjunctiva of SJS patients.

Labial mucosa grafting for lid margin, anterior lamellar, and posterior lamellar correction in recurrent cicatricial entropion

PURPOSE

To report a novel modified technique for severe recurrent cicatricial entropion correction based on anterior lamellar recession (ALR) and grafting.

METHODS

Six eyelids of five patients (9-48 years; three females) with severe cicatricial entropion (three upper and three lower eyelids) had surgical correction using ALR and labial mucosal grafting for spacing the ciliary margin away from the lid margin and reconstruction of the lid margin and posterior lamella. The modified technique included using mucous membrane as a single unit for anterior lamella, lid margin, and posterior lamella reconstruction employing a different suturing technique.

RESULTS

The indications for surgery included Stevens-Johnson syndrome (3), chemical injury (2), and post-surgical scarring in congenital distichiasis with lymphedema (1). Entropion resolved in all patients with restoration of eyelid margin and reduction in ocular discomfort. Trichiasis was present in all six eyelids (100%) preoperatively and resolved completely in all but one case (83% success rate) with three residual focal trichiatic lashes in the temporal area, which was successfully managed with radiofrequency ablation. There were no recurrences of trichiatic or distichiatic lashes at a median follow-up duration of 16 months (range, 12-18 months).

CONCLUSION

Successful resolution of the recurrent cicatricial entropion can be achieved with the use of labial mucosa as one solution for spacing the anterior lamella and reconstruction of the lid margin and posterior lamella with minimal recurrence rate.

Lacrimal drainage anomalies in Tessier cleft 3 with unilateral anophthalmos

Bilateral Tessier cleft types 3 and 4 are rare and commonly involve the lacrimal drainage system owing to their anatomical location. Such clefts commonly present with associated ocular anomalies and include colobomatous eyelids, hypertelorism, microphthalmia, punctal or canalicular agenesis, and nasolacrimal duct obstruction or exstrophy. The current report presents an 18-month-old baby with bilateral Tessier cleft 3 with a unilateral anophthalmos, symmetrical eyelid colobomas, and lacrimal drainage anomalies. The lacrimal anomalies noted include small lacrimal sac with inferior canaliculus on the right side and upper and lower punctal and canalicular agenesis on the left side. Computed tomographic dacryocystography demonstrated unilateral lacrimal sac and bilateral maldevelopment of the bony nasolacrimal duct.

Abstract PD9-07: A phase II study of copper-depletion using tetrathiomolybdate (TM) in patients (pts) with high risk breast cancer (BC): Role of collagen processing and tumor microenvironment

Background: Copper is an important catalytic cofactor in several biological functions and is essential for lysyl oxidase (LOX), a key enzyme in cross-linking collagen, which may play a role in tumor metastasis. We hypothesized that tetrathiomolybdate (TM)-associated copper depletion (CD) would inhibit tumor metastases by altering copper dependent collagen remodeling in the pre-metastatic niche. These results are an update of our previously reported clinical outcomes with longer follow-up and translational outcomes implicating the tumor microenvironment in metastatic transformation of BC. Methods: Pts at high risk for recurrence, node+ triple negative (TNBC) or stage 3/4 BC with no evidence of disease (NED), were enrolled on a phase II study of CD with TM. TM was given to maintain ceruloplasmin (Cp) levels between 8-16 mg/dl for two years (yrs) with an extension phase or until relapse. Median Cp levels were monitored with each cycle. Clinical endpoints included safety/tolerability and progression of disease (POD)/death. Event-free (EFS) and overall survival (OS) were calculated using Kaplan Meier survival analyses. Translational endpoints included markers of collagen cross-linking (LOXL-2), formation (PRO-C3), and degradation (C1M and C6M). Results: Seventy-five pts received 2993 cycles of TM on the primary (24 cycles, 28 days per cycle) and extension study. Median age was 51 yrs (range 29-66). Forty-five pts had stage 2/3 BC, and 30 pts were stage 4 NED. At a median follow-up of 8.4 yrs, the overall EFS was 71.4% and OS was 78.8%. The EFS and OS for the 36 pts with TNBC were 71.7% and 81%, and the EFS and OS for the 39 pts with Luminal/HER2+ BC were 71.2% and 78.6% respectively. TM was well tolerated with grade 3/4 toxicities including: neutropenia (1.9%), febrile neutropenia (0.03%), and fatigue (0.2%). LOXL2 levels were significantly decreased at 12 and 24 cycles compared with baseline (p&lt;0.01) in those who were NED but not in those who had progressive disease (POD). LOXL2 levels were significantly correlated with C1M levels (spearman coefficient -0.34, p=0.02). C1M levels were significantly increased at 5, 11 and 24 cycles as compared with baseline (p&lt;0.01) in those who were NED and were significantly higher as compared to levels in those experiencing POD/death, p&lt;0.05. This difference may be more pronounced in those not achieving adequate CD (&lt;50%) and in luminal/HER2+ BC. Interestingly, the ratio of C1M/PRO-C3 was significantly more elevated over time in those NED as compared to those experiencing POD/death. No associations were found with other collagen markers (PRO-C3 and C6M). Conclusions: TM is safe, well-tolerated and associated with decreased LOXL-2 and increased C1M levels over time in NED pts. This suggests that copper depletion may result in decreased collagen crosslinking and increased collagen degradation over formation, potentially “normalizing” the collagen microenvironment to create an inhospitable environment for tumor metastases. Larger randomized trials in high risk populations with translational outcomes are needed to further investigate the role of collagen processing in the tumor microenvironment and its potential as a biomarker of response.

Citation Format: Liu YL, Bager CL, Willumsen N, Kornhauser N, Cobham M, Andreopoulou E, Cigler T, Moore A, LaPolla D, Fitzpatrick V, Ward M, Warren JD, Mittal V, Vahdat LT. A phase II study of copper-depletion using tetrathiomolybdate (TM) in patients (pts) with high risk breast cancer (BC): Role of collagen processing and tumor microenvironment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD9-07.

Primary limbal stem cell transplantation in the surgical management of extensive ocular surface squamous neoplasia involving the limbus

Purpose

To determine the role of primary limbal stem cell transplantation (LSCT) in managing extensive ocular surface squamous neoplasia (OSSN) with more than 3 quadrants of limbal involvement to prevent manifestations of limbal stem cell deficiency.

Methods

A multi-center, comparative, and interventional clinical study of cases and historical controls was done. Patients with a limbal mass suggestive of OSSN involving more than 3 quadrants of limbus (> 9 clock hours) and no local, regional or systemic metastasis, who underwent primary surgical excision with or without adjuvant chemotherapy and had a minimum follow-up of 12 months were included in this study. Two historical controls underwent tumor excision with only amniotic membrane grafting. Three cases underwent tumor excision along with LSCT in the form of conjunctival limbal autograft (CLAG) or simple limbal epithelial transplant (SLET).

Results

None of the eyes had any recurrences of OSSN during the follow-up period. Cases with primary LSCT with tumor excision showed better ocular surface stability in the long term.

Conclusion

Concomitant LSCT either in the form of CLAG or SLET appears to provide better long-term outcomes and is advocated while excision of extensive OSSN involving the limbus.

Utility of intraocular endoscope for lacrimal canaliculi and sac examination

PURPOSE

Intraocular endoscope was used as a dacryoendoscope, and its observations and performance in lacrimal drainage system (LDS) are reported.

METHODS

The Endo Optiks (Little Silver, New Jersey, USA), an intraocular endoscope (modified with customized sheath), was used for LDS visualization in ten normal adults and five patients with lacrimal disorders.

RESULTS

We were able to capture high-definition images of lacrimal canaliculi and sac in all normal adults. Smooth whitish canalicular mucosa with lumen could be appreciated in all normal individuals. Common canaliculus showed variable folds among individuals and reddish lacrimal sac mucosa could be appreciated with great details. In patients with canalicular obstruction, site of obstruction was presented as whitish gray area with no visible lumen, which could be opened up precisely with trephination. No false passage was formed in any of the cases. One of the cases had membranous canalicular obstruction, which was opened with probe itself. Nasolacrimal duct could not be examined due to the shorter length of the probe.

CONCLUSION

Intraocular endoscope can be used as high-resolution dacryoendoscope for visualization of lacrimal canaliculi and sac.

Bilateral herpes simplex keratitis reactivation after lacrimal gland botulinum toxin injection

Botulinum toxin A (BTA) injections into lacrimal gland are being used for refractory epiphora due to intractable lacrimal disorders with success rates reported from 18% to 86%. Most common side effects are transient ptosis and diplopia. We report a case of a 59-year-old female injected with 2.5 units of BTA injection in each lacrimal gland for functional epiphora. The patient had a history of herpes simplex viral keratitis that was quiescent for more than 2 years. After 3 weeks, she developed reactivation of viral keratitis bilaterally, which was successfully managed with antivirals and topical steroids. Reactivation of quiescent herpes simplex keratitis is a possibility after lacrimal gland BTA and caution should be exercised in such cases.

Ethylene-co-Vinyl Acetate/MWCNTs/Hectorite Elastomeric Nanocomposites: Characterization and Electrical Properties

MWCNTs/hectorite 3D hybrid filler was prepared from the 1:1 combination by weight of constituent MWCNTs (1D) and hectorite (2D) through simple dry grinding method. The resulting hybrid filler was subsequently utilized for the preparation of Ethylene-co-vinyl acetate (EVA)/MWCNTs/hectorite nanocomposites by solution intercalation method. Transmission electron microscopy and X-ray diffraction studies of the nanocomposites confirm homogeneous dispersion of the fillers in the polymer matrix. Mechanical, thermal and dielectric properties of neat EVA are significantly enhanced with increase in filler content. The improvement in tensile properties observed at 4 wt.% filler content are: 243% in tensile strength (1.78 MPa to 6.11 MPa), 105% in elongation at break (366% to 750%) and 426% in toughness (3.36 MPa to 17.67 MPa) without significant change (1.12 MPa to 1.31 MPa) in Young's modulus. Differential scanning calorimetry confirms significant increase in crystallinity, crystallisation temperature (Tc) and crystallite melting temperature (Tm) of the nanocomposites vis-a-vis neat EVA. Observed shift in Tc by more than 10 °C (~87 to ~98 °C) and Tm by more than 30 °C (~118 to ~151 °C) are really significant confirming the improved thermal stability of the nanocomposites. Maximum improvements in dielectric constant and AC conductivity observed at 5 wt.% hybrid filler content are ~25% and ~50% respectively. Superior mechanical properties of the nanocomposites combined with enhanced thermal stability and dielectric properties make it a prospective material for flexible dielectric applications. Properties attained can be attributed to improved polymer-filler interaction on account of homogeneous dispersion.

Abstract P1-10-02: A phase II study of copper-depletion using tetrathiomolybdate in patients with breast cancer at high risk for recurrence: Updated results

Background: Metals have emerged as a viable therapeutic target for a new generation of anti-cancer and anti-metastatic agents. Copper, an essential trace element, serves as an important catalytic cofactor in several biological functions and has emerged as an essential factor in carcinogenesis. Among other elements, bone marrow derived VEGFR2+ endothelial progenitor cells (EPCs) and copper-dependent lysyl oxidase (LOX) are key elements in tumor progression. We hypothesized tetrathiomolybdate (TM)-associated copper depletion (CD) inhibits tumor metastases by reducing the number of EPCs and other copper dependent processes in the pre-metastatic niche. These results are an update of our previously reported study (Chan N, Willis A, Kornhauser N et al. Influencing the Tumor Microenvironment: Phase 2 Study of Copper Depletion with Tetrathiomolybdate in High Risk Breast Cancer and Preclinical Models of Lung Metastases. Clin Cancer Res. October 21, 2016) with longer follow-up.

Methods: A single arm phase II study of breast cancer (BC) patients (pts) at high risk for recurrence, defined as node+ triple negative (TNBC), stage 3 and 4 with no evidence of disease (NED) were enrolled on a trial of CD with TM. TM was given to maintain ceruloplasmin (Cp) levels between 8-16 mg/dl for two years with an extension phase or until relapse. The primary endpoint was a change in EPCs measured by flow cytometry before and during treatment. Secondary endpoints included tolerability, safety, PFS and LOXL-2 levels.

Results: Seventy-five pts received 2778 cycles of TM on the primary and extension study. The primary study treatment duration was 24 cycles (each cycle is 28 days) plus an extension phase. The median age is 51 years (range 29-66). Forty-five pts have stage 2/3 BC and 30 with stage 4 NED. Forty-eight percent of pts are TNBC and 40% of pts are stage 4 NED. Median Cp levels were monitored with each cycle. A decrease from 28 to 16 (p&lt;0.0001) was seen after one cycle. Interestingly, TNBC pts seemed to have a greater decrease from 23.5 to 13 after one cycle. TM was well tolerated with grade 3/4 toxicities including: reversible neutropenia (2.3%), febrile neutropenia (0.04%), fatigue (0.2%). Five-year analysis showed a decrease in EPC's (p=0.004) and LOXL-2 (p&lt;0.001). At a median follow-up of 7.1 years, the EFS for 75 pts is 71.4%. The EFS for 36 pts with TNBC is 71.7%. EFS for stage 2/3 TNBC is 83% and for stage IV TNBC is 59.3%.

Conclusions: TM is safe, well tolerated and appears to affect multiple components of the tumor microenvironment that have been identified in pre-clinical models as important for progression. Ongoing studies in banked specimens are underway to further delineate its effect on copper dependent processes necessary for metastases. Randomized trials are warranted, especially in patients who are at high risk for relapse such as those with TNBC.

Citation Format: Sahota S, Willis A, Kornhauser N, Ward M, Cobham M, Cigler T, Moore A, Andreopoulou E, Fitzpatrick V, Schneider S, Prima N, Wiener A, Ko D, De Laurentiis A, Warren JD, Rubinchik A, Mittal V, Vahdat LT. A phase II study of copper-depletion using tetrathiomolybdate in patients with breast cancer at high risk for recurrence: Updated results [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 P1-10-02.

Spectral domain optical coherence tomography for measuring tear film meniscus height and its relationship with epiphora

Purpose:

To evaluate the relationship between tear meniscus height (TMH) values measured by optical coherence tomography (OCT) and the severity of epiphora (Munk scoring).

Methods:

In this prospective cross-sectional study, consecutive patients with epiphora were studied. All patients underwent Munk epiphora scoring, lacrimal syringing, and detailed ophthalmological examination. Using OCT, the TMH (i.e., the line intersecting level of tear meniscus and lower eyelid) values were calculated. The relationship between TMH and epiphora was analyzed by comparing TMH values across various grades of epiphora using Kruskal–Wallis test.

Results:

A total of 38 patients (56 eyes) were included. The mean age was 55 ± 11.1 years with equal distribution of males and females. The mean TMH values were 238 ± 141.3, 396.6 ± 159.5, 707.1 ± 288.8, and 809.5 ± 419.4 μm in grades 1, 2, 3, and 4 of epiphora, respectively. A significant difference in TMH was found among grades 2, 3, and 4 (P = 0.0007). On post hoc analysis, only grade 2 was significantly different from grades 3 and 4 (P = 0.0008 and P = 0.002 respectively), but grades 3 and 4 were comparable (P = 0.62).

Conclusion:

Levels of TMH were found to increase with increasing severity of epiphora. TMH values were comparable in Munk grades 3 and 4.

Enhancement of bulk second-harmonic generation from silicon nitride films by material composition

We present a comprehensive tensorial characterization of second-harmonic generation from silicon nitride films with varying compositions. The samples were fabricated using plasma-enhanced chemical vapor deposition, and the material composition was varied by the reactive gas mixture in the process. We found a six-fold enhancement between the lowest and highest second-order susceptibility, with the highest value of approximately 5 pm/V from the most silicon-rich sample. Moreover, the optical losses were found to be sufficiently small (below 6 dB/cm) for applications. The tensorial results show that all samples retain in-plane isotropy independent of the silicon content, highlighting the controllability of the fabrication process.