Carotid cavernous fistula masquerading as orbital inflammation on noninvasive imaging in a peripartum patient.

A carotid cavernous fistula (CCF) is a pathological connection between the internal or external carotid artery and the cavernous sinus venous system. Pregnancy has been proposed as a risk factor for spontaneous CCF, but the exact mechanism of risk is unknown. Overall, there are few published reports describing CCF in pregnancy. Study of this risk factor relationship is further complicated by potential ambiguity in diagnosing CCF, which may present as subtle, nonspecific findings on initial workup. We report a case of CCF during pregnancy in which the diagnostic process was notable for misleading, noninvasive, imaging studies.

Is primary open-angle glaucoma an ocular manifestation of systemic disease?

Primary open-angle glaucoma is currently characterized by a pattern of progressive retinal ganglion cell loss that stems from a complex underlying pathophysiology that remains poorly elucidated. The roles of blood flow and intraocular pressure (IOP) in glaucoma pathogenesis have been extensively studied. Further, it has been established that lowering IOP can slow the progression of glaucoma. In addition, a number of influential factors have emerged and gained momentum over the years. Increasing evidence implicates the contributions of low cerebrospinal fluid pressure, autoimmunity, neurodegeneration, and impaired autoregulation towards glaucoma pathophysiology. We aggregate and explore these different camps of thought that have garnered attention over the last few decades, and, in doing so, aim to challenge the long-standing view of glaucoma as a primary disease of the eye. A shift in our perspective towards understanding glaucoma as an ocular manifestation of systemic dysregulation may lead ultimately to better clinical management of the disease.

Usefulness of left ventricular strain analysis in patients with takotsubo syndrome during acute phase.

BACKGROUND: Takotsubo syndrome (TTS) is peculiar clinical condition often resembling an acute coronary syndrome and mostly affecting postmenopausal women after a stressful trigger. TTS was initially thought to be a relatively benign condition. However, current data have shown it may be associated with considerable inpatient morbidity and carry a small, but important, mortality risk. METHODS: We hypothesized that left ventricular (LV) regional and global longitudinal strain (GLS) assessed with 2D speckle tracking echocardiography could identify early systolic functional impairment and predict in-hospital cardiovascular events. We conducted a retrospective descriptive study reviewing patients with the discharge diagnosis of TCM between 2003 and 2016 at our institution. RESULTS: One hundred patients with TSS met the Modified Mayo Clinic criteria. Using 2D speckle tracking echocardiography, two independent cardiologists assessed the LV GLS as well as the longitudinal strain (LS) of 7 individual segments [basal-septal (BS); mid-septal (MS), apical-septal (AS), apex, basal-lateral (BL), mid-lateral (ML), and apical-lateral (AL)]. The inter-observer variability was <5%. Mean age was 69.1 years, 87% were females, and 53% were African Americans. Mean initial LV EF was 32% ± 9.8%. In univariate analysis, patients with worse BL, ML, and GLS profiles (means: -5.7; -3.3, and -4, respectively) had higher in-hospital mortality (P < .05). Worse BL and ML profiles (means: -8.6 and -7.3, respectively) were associated with higher prevalence of MACE (major adverse cardiovascular outcomes) (P < .05). In a multivariate analysis, mid-lateral strain ≥ -7 and basolateral strain ≥ -10 were independent predictors of in-hospital mortality and MACE + in-hospital heart failure, respectively. CONCLUSIONS: Assessment of LV global and segmental longitudinal strain by speckle tracking has important prognostic value in the acute phase of TTS. Additional large-scale studies will be needed to confirm our findings.

Surgical Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Patients With Open-angle Glaucoma.

PURPOSE: To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with open-angle glaucoma. PARTICIPANTS AND METHODS: A retrospective chart review of adult patients who underwent GATT due to inadequately controlled intraocular pressure (IOP) or intolerance to medication. Main outcome measures were success rate, IOP, and number of glaucoma medications. Success was defined as IOP reduction >20% from baseline or IOP between 5 to 21 mm Hg, and no need for further glaucoma surgery. When success criteria were not met for any postoperative visit >3 months after surgery, failure was determined. RESULTS: In total, 66 patients, average age 62.9±14.9 years (50.8% female) were included in the analysis. Average follow-up was 11.9 months (range, 3 to 30 mo) and overall success rate was 63.0%. Mean IOP was 26.1±9.9 mm Hg preoperatively and 14.6±4.7 mm Hg at 12 months (44% IOP decrease; P<0.001). Mean number of medications decreased from 3.1±1.1 preoperatively to 1.2±0.9 at 12 months (P<0.001). No significant differences between patients with primary open-angle glaucoma and other types of glaucoma were found.The rate of hyphema at 1 week and 1 month postoperatively was 38% and 6%, respectively. Overall GATT success rate among white and black patients was 69% and 42%, respectively, which was statistically significant (P<0.05). CONCLUSIONS: The future of GATT as a minimally invasive glaucoma surgery in adults seems promising. This position is supported by its low rate of long-term complications and the conjunctiva-sparing nature of the surgery.

The relationship between contrast sensitivity and retinal nerve fiber layer thickness in patients with glaucoma.

PURPOSE: To evaluate the correlation between contrast sensitivity (CS) and retinal nerve fiber layer (RNFL) in different areas of vision. METHODS: This report is a sub-analysis of a prospective, observational cohort study investigating changes in performance-based assessment, vision-related quality of life, and clinical measures in patients with moderate to advanced glaucoma. The study included 161 participants with at least a 2-year history of glaucoma who underwent annual testing for 4 years. Contrast sensitivity was measured using the Spaeth/Richman contrast sensitivity (SPARCS) test, while RNFL thickness (RNFLT) was measured using Cirrus optical coherence tomography (OCT). Statistical analyses were performed to determine correlations between CS and RNFLT; the correlations were calculated for each annual visit, totaling four correlation coefficients for each patient over the course of 4 years. RESULTS: The SPARCS score in the left upper area of vision correlated the most strongly with the RNFLT of the inferior quadrant for both eyes at each annual visit, specifically in the seven o'clock sector for the left eye and the six o'clock sector for the right eye (p < 0.05). There were no discernible trends for the correlations between the other areas of CS and RNFL quadrants or clock hours over the 4 years of the study. Linear regression between the SPARCS total score and average RNFLT showed a significant direct correlation at each visit (p < 0.01). CONCLUSIONS: Contrast sensitivity in the left upper area of vision for both eyes correlated most strongly with the thickness of the inferior quadrant of the RNFL. These fibers project to the temporal portion of the right occipital lobe, implying a potential center for contrast perception in this area. The longitudinal nature of the study suggests that CS may be a predictive tool for changes in RNFL in patients with glaucoma. Despite this finding, retinal damage and its relationship to CS was diffuse. In addition, SPARCS was shown to predict RNFLT. Further research is warranted to understand how CS can be used as a tool in the clinical setting.

Incidence and predictors of stroke during the index event in an ethnically diverse Takotsubo cardiomyopathy population.

Takotsubo cardiomyopathy (TTS) is a peculiar clinical condition often affecting postmenopausal women after a stressful trigger. The underlying mechanisms have not been completely elucidated but several hypotheses have been advanced, with catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasm each suggested to play a role. The incidence of stroke after TTS appears to range from 0% to 7.7%, and interestingly TTS has been described as both a cause and a complication of stroke. We sought to assess the incidence and predictors of stroke during the index event (peri-index event stroke) in a heterogeneous TTS population. We conducted a retrospective descriptive study reviewing patients who were discharged with a diagnosis of TTS from the Einstein Medical Center, Philadelphia, PA and Danbury Hospital, Danbury, CT in the period between 2003 and 2014. A total of Incidence and predictors of stroke during the index event in an ethnically diverse Takotsubo cardiomyopathy population 206 patients met the modified Mayo Clinic criteria and were included in the study. The patients' overall mean age was 67.8 years; 87% (n=179) were females and 25% (n=53) were African Americans. The following incidence rates were found: stroke 7%, in-hospital heart failure 26.7%, and in-hospital death 7%. On multivariate analysis independent predictors (expressed as odds ratios with 95% confidence intervals) of periindex event stroke were: i) African American race (OR 3.2, 95% CI 1.2-10.2, p=0.048); ii) hypertension (OR 10.5, 95% CI 1.3-88, p=0.03). ACE inhibitor use was a protective factor for developing peri-index event stroke (OR 0.15, 95% CI 0.04-0.5, p=0.001). There was a trend towards dual antiplatelet therapy (DAPT) being protective for stroke (OR 0.3, 95% CI 0.05-1.1, p=0.08). The incidence of peri-index event stroke was 7%. African American race and hypertension were found to be independent predictors of peri-index event stroke. Prospective clinical trials are needed to confirm these findings and to better determine the impact of hypertension as a risk factor for stroke and to assess the role of DAPT in preventing it.