Reduced narcotic and sedative utilization in a NICU after implementation of pain management guidelines.

OBJECTIVE: To assess the opioid and benzodiazepine usage in a level IV NICU after implementation of pain guidelines. STUDY DESIGN: Guidelines were developed for infants undergoing surgical procedures and infants on mechanical ventilation. Data collected for period 1 (July to December 2013) and period 2 (March to August 2014). RESULTS: Gestational age, birth weight and infants with hypoxic respiratory failure or requiring major procedures were comparable in two periods. Number of patients exposed to opioids decreased from 62.9% (129/205) in period 1 to 32.8% (82/250) in period 2, P=<0.001. Cumulative dose exposure decreased, opioids in morphine equivalent dose, mg kg-1 (1.64 (0.38 to 6.94) vs 0.51 (0.04 to 2.33), P=0.002), sedatives in midazolam equivalent, mg kg-1 (0.16 (0.03 to 7.39) vs 0.10 (0.00 to 4.00), P=0.03). Ten patients required treatment for iatrogenic opioid withdrawal versus only three in post guideline, P=0.02. CONCLUSIONS: Evidence-based guidelines led to significant reduction in opioids and sedatives exposure, and in the number of infants requiring methadone for iatrogenic narcotic dependence.

Needle aspiration and endodiathermy treatment of epithelial inclusion cyst of the iris.

PURPOSE: To report a case of recurrent epithelial inclusion cyst of the iris treated with needle aspiration and endodiathermy. METHODS: Case report. A 27-year-old man with a history of congenital cataracts, congenital nystagmus, cataract surgery in each eye at 3 years of age, and a long-standing iris epithelial cyst presented with decreased vision of 20/400 in the better seeing left eye. The reduced vision was diagnosed secondary to growth of the iris inclusion cyst over the pupil. RESULTS: The iris cyst, which occluded the chamber angle and pupil, was treated with aspiration, separation of the cyst wall from the cornea, and endodiathermy. Twelve months after cyst surgery, no evidence existed of epithelial cyst regrowth. The visual function was significantly improved, although Snellen visual acuity was unchanged at 20/400. CONCLUSION: The minimal invasiveness of needle aspiration and diathermy can result in a satisfactory outcome without undertaking more extensive and invasive surgical treatments for epithelial inclusion cysts of the anterior chamber.

High-resolution magnetic resonance imaging evaluation of blood-retinal barrier integrity following transscleral diode laser treatment.

OBJECTIVE: To compare the effects of contact transscleral diode laser treatment and retinal cryotherapy on blood-retinal barrier integrity with the use of high-resolution magnetic resonance imaging techniques with constant infusion of gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA). METHODS: Transscleral diode laser photocoagulation and retinal cryotherapy were used to treat equivalent areas of the inferior retinal periphery of pigmented rabbits. Magnetic resonance imaging time-course studies with measurement of signal enhancements due to Gd-DTPA leakage were conducted 2 and 15 days following treatment. RESULTS: Two days following treatment, cryotherapy-treated eyes exhibited a mean (+/- SD) effective Gd-DTPA permeability coefficient of 4.6 +/- 0.8 x 10(-6) cm/s; in comparison, diode laser-treated eyes exhibited 1.6 x 1.4 x 10(-6) cm/s effective permeability. Significant decreases in the effective permeability were also noted 15 days after treatment in both groups. CONCLUSIONS: Transscleral contact probe diode laser photocoagulation induces less disruption of the blood-retinal barrier than does conventional cryotherapy. In addition, the continuous infusion method of Gd-DTPA delivery is a reliable and easily interpretable alternative to the commonly used bolus injection approach.

Postoperative fibrin formation and visual outcome after pars plana vitrectomy.

PURPOSE: To determine whether postvitrectomy fibrin formation was associated with visual outcome, a prospective study of patients undergoing pars plana vitrectomy was performed. METHODS: In 121 patients undergoing vitrectomy at the Medical College of Wisconsin between July 1986 and April 1989, the association of fibrin formation and other perioperative factors with visual outcome was evaluated by univariate and multivariate regression analysis. Poor visual outcome was defined as visual acuity worse than 5/200. RESULTS: After a median follow-up period of 23 months (range 6 to 51 months), patients with severe fibrin formation experienced a higher rate of poor visual outcome (19 of 26 patients, 73%) than patients with little or no fibrin formation (23 of 95 patients, 24%; P < 0.0001, univariate analysis). After adjusting for a variety of factors with multivariate regression analysis, fibrin formation was not significantly predictive of final visual outcome. CONCLUSIONS: Factors associated with postvitrectomy fibrin formation may affect visual outcome more than fibrin formation itself.

Surgical removal of an extrafoveal fibrotic choroidal neovascular membrane with foveal serous detachment in age-related macular degeneration.

BACKGROUND: Visual recovery after submacular surgery for age-related macular degeneration (AMD) has been very limited. METHODS: A patient with an extrafoveal fibrotic choroidal neovascular membrane from AMD had an overlying serous foveal detachment with the fibrotic tissue elevating the foveal retina. Photocoagulation of the neovascular membrane was not recommended because of its nonpigmented, fibrotic nature. The membrane was surgically excised. RESULTS: Preoperative and postoperative visual acuity and central 30 degrees visual fields were followed. Visual acuity improved from 20/200 to 20/25, and a preoperative central scotoma resolved completely 18 months after surgical excision of the extrafoveal fibrotic neovascular membrane. There were no intraoperative or postoperative complications. CONCLUSION: This type of patient may represent a distinct subset of patients with AMD amenable to subretinal surgery who could potentially have good recovery of vision.

In vivo determination of the anisotropic diffusion of water and the T1 and T2 times in the rabbit lens by high-resolution magnetic resonance imaging.

PURPOSE: Several magnetic resonance imaging (MRI) "tools" for ophthalmologic research have recently been developed in this laboratory, including improved gradient and radiofrequency coils and pulse sequences for high-resolution and diffusion imaging (100-microns resolution). METHODS: These tools have been applied to the in vivo measurement of the relaxation parameters (T1 and T2) and the water diffusion coefficients (Dx and Dy) in the rabbit eye lens, both normal and cataractous. Maps of these parameters in the lens have been computer generated. RESULTS: In the normal lens, water diffusion is highly anisotropic and tends to be parallel to the surface. In the trauma-induced cataractous lens, an increase in spin-spin relaxation times (T2) consistent with edema and alteration of diffusion patterns was observed in a study conducted 2 weeks postsurgery. A partial reversal was observed 6 weeks postsurgery. The histologic data on the enucleated lens at 6 weeks showed a loss of normal lens architecture. Images are shown that display other small structures of the anterior segment with great clarity. CONCLUSIONS: An extension of this work, now underway, is the study of the formation of various types of cataract in animal models. It is hypothesized that these methods can be extended to humans as a quantitative alternative for the assessment of cataracts.

Modulation of potassium transport in cultured retinal pigment epithelium and retinal glial cells by serum and epidermal growth factor.

The ionic environment of retinal photoreceptors is partially controlled by potassium transporters on retinal glial and retinal pigment epithelial cells (RPE). In this study, serum and epidermal growth factor (EGF) were examined as modulators of potassium transport in confluent cultures of human RPE and rabbit retinal glia. EGF is a known mitogen for confluent RPE cultures and was shown here to also stimulate [3H]thymidine incorporation in cultures of retinal glia. For potassium transport studies 86Rb was used as a tracer during a 17-min incubation. For both retinal cell types the mean total 86Rb uptake in 10% serum was approximately 60% above basal, serum-free controls. For EGF, tested in several experiments in a concentration range from 1 to 100 ng/ml, maximal total uptake was 33 and 24% above controls for RPE and glia, respectively. Inhibitor studies suggested that basal and serum-stimulated uptake for both cell types occurred by the ouabain-sensitive Na-K ATPase pump and by the furosemide- or bumetanide-sensitive Na-K-Cl cotransporter. EGF-stimulated uptake appeared to be due predominantly to the cotransporter. The data suggest that serum components and EGF, which may be available to retina-derived cells under pathologic conditions, may not only stimulate proliferation but may also act as short-term modulators of potassium ion movement and thus affect physiologic processes that are sensitive to ion homeostasis.

Pupillary and electroretinographic abnormalities in a family with neuronal intranuclear hyaline inclusion disease.

Abnormal pupillary function and a severely depressed electroretinogram were found in four members of a family with neuronal intranuclear hyaline inclusion disease, an idiopathic degenerative disorder that involves the central and peripheral nervous systems. Symptoms were limited to the gastrointestinal system and consisted principally of abdominal pain, constipation, and severe weight loss. The discovery of light-fixed pupils in the propositus led to the first antemortem diagnosis by rectal biopsy in two generations of this family. Abnormalities of gastrointestinal motility and pupillary reactions constituted the only objective evidence of autonomic dysfunction; the abnormal electroretinogram was the only evidence of central nervous system dysfunction.

Prophylactic treatment to the fellow eye of patients with phakic lattice retinal detachment: analysis of failures and risks of treatment.

The authors performed a retrospective analysis on 296 phakic patients who had bilateral lattice degeneration and a retinal detachment in one eye. The analysis was done to determine the complications of full prophylactic treatment to lattice and breaks in the fellow eye and to explain the reasons that this treatment sometimes did not prevent new retinal breaks or detachments. The patients were followed for a mean +/- SD of 7.415 +/- 5.422 years after their first detachment. Twenty-four new tears occurred in the fellow eyes during this time, seven (29.2%) of which were away from areas of visible lattice. Prophylactic treatment did not appear to cause new tears or increase the risk of detachment if a new tear occurred. It also did not compromise the surgical repair in those patients who had eyes in which new breaks or detachments developed. The risk of visual loss was similar in those patients receiving prophylactic treatment compared with those not receiving treatment.

The fellow eye of patients with phakic lattice retinal detachment.

A retrospective study was performed to determine whether the prophylactic treatment of areas of lattice degeneration, holes, or breaks reduced the risk of subsequent new breaks or detachment in the fellow undetached phakic eyes of patients with a phakic lattice retinal detachment (RD). Three hundred eighty-eight consecutive patients who presented to the University of Iowa between 1959 and 1984 were followed for a mean of 7.9 +/- 5.8 years after the detachment in the first eye. Fellow eyes which received no prophylactic treatment had a 2.5 times greater risk of a new break or RD over 7 years than eyes receiving full prophylactic treatment (19.4 versus 7.5%; P = 0.0002). Fellow eyes receiving no treatment also had a greater risk of a new RD over 7 years than eyes receiving full treatment (5.1 versus 1.8%; P = 0.0125). These results do not allow us to make recommendations concerning which fellow eyes, if any, should be prophylactically treated. On the one hand, prophylactic treatment did significantly reduce the risk of new breaks and detachments. On the other hand, however, prophylactic treatment reduced the risk of new RD alone in the fellow eye only from 5.1 to 1.8% over 7 years. In addition, prophylactic treatment did not reduce the risk of detachment in the higher risk eyes with high myopia or extensive lattice.