Patterns of ocular trauma in elderly patients in an urban population-the Bronx experience / Padrões de trauma ocular em pacientes idosos em uma população urbana - a experiência de Bronx

ABSTRACT Purpose: To evaluate the characteristics of ocular injuries among elderly patients admitted to an urban level I trauma center because of major trauma from 2008 to 2015. Methods: A retrospective chart review was conducted of patients aged >65 years admitted with ocular injuries that were identified with ICD-9 codes. Tabulated data were analyzed using the Student's paired t-test, the chi-squared test, and regression analysis using STATA/MP-12 software. Significance was set at p<0.05. Results: Of a total of 861 patients, 221 (25.7%) admitted for major trauma and ocular injuries were elderly. The mean age of these patients was 80.3 years (median =79.2 years; interquartile range=63.8-94.6 years). Of these patients, 40.7% were males and 59.3% were females. The males were younger than the females (mean age, 77.3 vs. 82.4 years, respectively, p<0.001). Race was documented as white (30.8%), black (13.6%), and "other" (54.3%), with 67.5% of the "other" group (36.7% overall) identified as Hispanic. The most frequent injuries were contusion of the eye/adnexa (68.2%), orbital wall fractures (22.2%), and an open wound of the ocular adnexa (18.1%). Males had a 2.64-fold greater risk of orbital wall fractures (95% confidence interval [CI]=1.38-5.05, p<0.003). Patients with orbital wall fractures had higher injury severity scores than those without (95% CI=14.1-20.9 vs. 6.8-8.6, respectively, p<0.001). The most common injuries were falls (77.8%) and pedestrian/motor vehicle accidents (6.8%). Falls occurred mostly at home (51.7%), on the street (13.9%), and in hospitals/nursing homes (12.2%). Those falling at home were older than those falling at other locations (95% CI=81.8-85.4 vs. 77.0-80.6 years, respectively, p<0.002). Conclusions: Ocular injuries in elderly Bronx patients most commonly occurred in females due to falls in the home/nursing home setting. Public health measures addressing identifiable individual and environmental risks in these common locations would be most beneficial in reducing the incidence of ocular injuries in this population.

RESUMO Objetivo: Avaliar as características das lesões oculares de idosos nas internações por grandes traumatismos em um centro urbano de trauma nível I de 2008 a 2015. Métodos: Realizou-se uma revisão retrospectiva de prontuários de pacientes com mais de 65 anos internados com lesões oculares identificados com os códigos CID-9. Os dados tabulados foram analisados com o teste t de Student, teste qui-quadrado e análise de regressão, utilizando o software STATA/MP-12. A significância estatística foi fixada em p<0,05. Resultados: Duzentos e vinte e um (25,7%) pacientes de um total de 861, admitidos por traumatismo craniano importante e lesões oculares, eram idosos. A idade média era de 80,3 anos (mediana=79,2; intervalo interquartil=63,8-94,6). 40,7% eram do sexo masculino e 59,3% do feminino. Os homens eram menos idosos (média=77,3) do que as mulheres (média=82,4), p<0,001. A raça foi documentada como branca (30,8%), negra (13,6%) e "outra" (54,3%); 67,5% dos "outros" (36,7% no geral) identificados como hispânicos. As lesões mais frequentes foram contusão do olho/anexos (68,2%), fraturas da parede orbital (22,2%) e ferida aberta dos anexos oculares (18,1%). Os homens tiveram 2,64 mais chances de fraturas da parede orbital (95% CI=1,38-5,05; p<0,003). Pacientes com fraturas da parede orbital tiveram maiores escores de gravidade da lesão (95% CI=14,1-20,9) do que aqueles sem fraturas (96% IC=6,8-8,6), p<0,001. Os mecanismos comuns foram quedas (77,8%) e acidentes a pé com veículos automotores (6,8%). As quedas ocorreram principal mente em casa (51,7%), na rua (13,9%) e em hospitais/lares de idosos (12,2%). Aqueles que caíram em casa eram mais velhos (IC 95%=81,8-85,4) do que os que tiveram quedas em outros locais (IC 95%=77,0-80,6), p<0,002. Conclusões: Lesões oculares em pacientes idosos de Bronx foram mais comuns no sexo feminino e devido a quedas que ocorreram em casa/lar de idosos. Medidas de saúde pública direcionadas a riscos individuais e ambientais identificáveis nesses locais comuns seriam mais benéficas na redução de lesões oculares nessa população.

Patterns of ocular trauma in elderly patients in an urban population-the Bronx experience.

PURPOSE: To evaluate the characteristics of ocular injuries among elderly patients admitted to an urban level I trauma center because of major trauma from 2008 to 2015. METHODS: A retrospective chart review was conducted of patients aged >65 years admitted with ocular injuries that were identified with ICD-9 codes. Tabulated data were analyzed using the Student's paired t-test, the chi-squared test, and regression analysis using STATA/MP-12 software. Significance was set at p<0.05. RESULTS: Of a total of 861 patients, 221 (25.7%) admitted for major trauma and ocular injuries were elderly. The mean age of these patients was 80.3 years (median =79.2 years; interquartile range=63.8-94.6 years). Of these patients, 40.7% were males and 59.3% were females. The males were younger than the females (mean age, 77.3 vs. 82.4 years, respectively, p<0.001). Race was documented as white (30.8%), black (13.6%), and "other" (54.3%), with 67.5% of the "other" group (36.7% overall) identified as Hispanic. The most frequent injuries were contusion of the eye/adnexa (68.2%), orbital wall fractures (22.2%), and an open wound of the ocular adnexa (18.1%). Males had a 2.64-fold greater risk of orbital wall fractures (95% confidence interval [CI]=1.38-5.05, p<0.003). Patients with orbital wall fractures had higher injury severity scores than those without (95% CI=14.1-20.9 vs. 6.8-8.6, respectively, p<0.001). The most common injuries were falls (77.8%) and pedestrian/motor vehicle accidents (6.8%). Falls occurred mostly at home (51.7%), on the street (13.9%), and in hospitals/nursing homes (12.2%). Those falling at home were older than those falling at other locations (95% CI=81.8-85.4 vs. 77.0-80.6 years, respectively, p<0.002). CONCLUSIONS: Ocular injuries in elderly Bronx patients most commonly occurred in females due to falls in the home/nursing home setting. Public health measures addressing identifiable individual and environmental risks in these common locations would be most beneficial in reducing the incidence of ocular injuries in this population.

Arginine and Carnitine Metabolites Are Altered in Diabetic Retinopathy.

Purpose: To determine plasma metabolite and metabolic pathway differences between patients with type 2 diabetes with diabetic retinopathy (DR) and without retinopathy (diabetic controls), and between patients with proliferative DR (PDR) and nonproliferative DR (NPDR). Methods: Using high-resolution mass spectrometry with liquid chromatography, untargeted metabolomics was performed on plasma samples from 83 DR patients and 90 diabetic controls. Discriminatory metabolic features were identified through partial least squares discriminant analysis, and linear regression was used to adjust for age, sex, diabetes duration, and hemoglobin A1c. Pathway analysis was performed using Mummichog 2.0. Results: In the adjusted analysis, 126 metabolic features differed significantly between DR patients and diabetic controls. Pathway analysis revealed alterations in the metabolism of amino acids, leukotrienes, niacin, pyrimidine, and purine. Arginine, citrulline, glutamic γ-semialdehyde, and dehydroxycarnitine were key contributors to these pathway differences. A total of 151 features distinguished PDR patients from NPDR patients, and pathway analysis revealed alterations in the ß-oxidation of saturated fatty acids, fatty acid metabolism, and vitamin D3 metabolism. Carnitine was a major contributor to the pathway differences. Conclusions: This study demonstrates that arginine and citrulline-related pathways are dysregulated in DR, and fatty acid metabolism is altered in PDR patients compared with NPDR patients.

Effect of Diabetes Mellitus and Metformin on Central Corneal Endothelial Cell Density in Eye Bank Eyes.

PURPOSE: To determine whether metformin use and diabetes mellitus (DM) affect central corneal endothelial cell density (ECD) by examining an eye bank corneal donor database. METHODS: The Lions Eye Institute corneal donor database, which consists of 38,318 corneal samples, was examined. Associations of ECD with metformin use and DM were tested by mixed effects linear models that account for correlations of outcomes between eyes within subjects adjusting for age, intraocular lens status, and glaucoma. Subjects (N = 17,056) with observed ECD counts for both eyes are included for analysis. RESULTS: Average donor age was 56.3 (SD = 15.0). ECD was not associated with metformin use (mean ± SE = 2592 ± 11.9 (N = 1014) versus nonuse [2592 ± 3.0 (N = 16,042), P = 0.302]; further analysis showed that ECD was not significantly associated with metformin use in patients with diabetes. However, metformin use was significantly associated with lower ECD among patients with glaucoma: [2658 ± 50.7 (N = 27) for use versus 2789 ± 19.0 (N = 164) for nonuse, P = 0.018]. The presence of DM was significantly associated with lower ECD 2581 ± 5.6 (N = 4766) for DM versus 2595 ± 3.4 (N = 12,290) for non-DM, P = 0.031). CONCLUSIONS: Lower ECD was associated with DM. Lower ECD was not associated with metformin use except in a subgroup of patients with glaucoma, in which subgroup analysis showed lower ECD. The differences in ECD observed were small and unlikely to affect the suitability for transplantation of donor corneas.

Mitochondrial Haplogroups Modify the Effect of Diabetes Duration and HbA1c on Proliferative Diabetic Retinopathy Risk in Patients With Type 2 Diabetes.

Purpose: We previously demonstrated an association between European mitochondrial haplogroups and proliferative diabetic retinopathy (PDR). The purpose of this study was to determine how the relationship between these haplogroups and both diabetes duration and hyperglycemia, two major risk factors for diabetic retinopathy (DR), affect PDR prevalence. Methods: Our population consisted of patients with type 2 diabetes with (n = 377) and without (n = 480) DR. A Kruskal-Wallis test was used to compare diabetes duration and hemoglobin A1c (HbA1c) among mitochondrial haplogroups. Logistic regressions were performed to investigate diabetes duration and HbA1c as risk factors for PDR in the context of European mitochondrial haplogroups. Results: Neither diabetes duration nor HbA1c differed among mitochondrial haplogroups. Among DR patients from haplogroup H, longer diabetes duration and increasing HbA1c were significant risk factors for PDR (P = 0.0001 and P = 0.011, respectively). Neither diabetes duration nor HbA1c was a significant risk factor for PDR in DR patients from haplogroup UK. Conclusions: European mitochondrial haplogroups modify the effects of diabetes duration and HbA1c on PDR risk in patients with type 2 diabetes. In our patient population, longer diabetes duration and higher HbA1c increased PDR risk in patients from haplogroup H, but did not affect PDR risk in patients from haplogroup UK. This relationship has not been previously demonstrated and may explain, in part, why some patients with nonproliferative DR develop PDR and others do not, despite similar diabetes duration and glycemic control.

Mitochondrial Haplogroups Affect Severity But Not Prevalence of Diabetic Retinopathy.

Purpose: We previously reported European mitochondrial haplogroup H to be a risk factor for and haplogroup UK to be protective against proliferative diabetic retinopathy (PDR) among Caucasian patients with diabetic retinopathy (DR). The purpose of this study was to determine whether these haplogroups are also associated with the risk of having DR among Caucasian patients with diabetes. Methods: Deidentified medical records for 637 Caucasian patients with diabetes (223 with DR) were obtained from BioVU, Vanderbilt University's electronic, deidentified DNA databank. An additional 197 Caucasian patients with diabetes (98 with DR) were enrolled from the Vanderbilt Eye Institute (VEI). We tested for an association between European mitochondrial haplogroups and DR status. Results: The percentage of diabetes patients with DR did not differ across the haplogroups (P = 0.32). The percentage of patients with nonproliferative DR (NPDR; P = 0.0084) and with PDR (P = 0.027) significantly differed across the haplogroups. In logistic regressions adjusting for sex, age, diabetes type, duration of diabetes, and hemoglobin A1c, neither haplogroup H nor haplogroup UK had a significant effect on DR compared with diabetic controls. Haplogroup UK was a significant risk factor (OR = 1.72 [1.13-2.59], P = 0.010) for NPDR compared with diabetic controls in the unadjusted analysis, but not in the adjusted analysis (OR = 1.29 [0.79-2.10], P = 0.20). Conclusions: Mitochondrial haplogroups H and UK were associated with severity, but not presence, of DR. These data argue that the effect of these haplogroups is related to ischemia and neovascularization, the defining features of PDR.

Ophthalmic manifestations of relapsing acute childhood leukemia.

Acute lymphoblastic leukemia is the most common malignancy in children. We report 3 patients who presented to their general pediatricians and pediatric oncologists with ocular complaints as the only evidence of their leukemic relapses. All patients presented with persistent conjunctival injection and were referred to an ophthalmologist for further management. Two patients were diagnosed with recurrent anterior uveitis, which after extensive workup and treatment with topical glucocorticoids was found to be a result of leukemic ocular disease. One patient had a conjunctival tumor, which was biopsied and confirmed to be leukemic infiltration. All children eventually succumbed to their recurrent disease. These cases demonstrate the need for a high index of suspicion when evaluating ocular symptoms in patients with a prior history of acute lymphoblastic leukemia. Anterior chamber paracentesis and biopsy of suspicious lesions should be considered as possible diagnostic procedures in addition to standard hematologic studies. Collaboration between a primary care physician, pediatric oncologist, and ophthalmologist is essential for optimal diagnosis and treatment.

Mitochondrial haplogroups are associated with severity of diabetic retinopathy.

PURPOSE: To determine if specific mitochondrial haplogroups associate with nonproliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR). METHODS: Deidentified medical records for Caucasian patients with diabetic retinopathy (DR; 153 NPDR and 138 PDR) were obtained from BioVU, Vanderbilt University's electronic, deidentified DNA databank. An independent cohort of Caucasian patients with DR (44 NPDR and 57 PDR) from the Vanderbilt Eye Institute (VEI) was used for validation. We tested for an association between mitochondrial haplogroups and PDR among patients with DR. RESULTS: In the BioVU cohort, PDR frequency among Caucasian DR patients differed significantly by mitochondrial haplogroup (P = 0.027). Replication in the VEI cohort confirmed this association (P = 0.0064). In the combined cohort, patients from the common haplogroup H were more likely to have PDR (odds ratio [OR] = 2.0 [95% confidence interval (CI) = 1.3-3.0], P = 0.0012), while patients from haplogroup Uk were less likely to have PDR (OR = 0.5 [95% CI = 0.3-0.8], P = 0.0049). In logistic regression analyses, the addition of diabetes duration, hemoglobin A1c (HgbA1c) levels, and hypertension had no effect on the associations of haplogroups H and Uk with PDR. CONCLUSIONS: In this study, DR patients from mitochondrial haplogroup H were more likely to have PDR, while DR patients from haplogroup Uk were less likely to have PDR. The association was independent of the major clinical variables affecting PDR. The mitochondrial haplogroups were as strong a risk factor for PDR as were elevated HgbA1c levels.