Optical Coherence Tomography Angiography for the Differentiation of Glaucoma from Pituitary Macroadenoma Related Optic Disc Measurements.

OBJECTIVE: To determine the potential of optical coherence tomography (OCT) and OCT angiography (OCTA) to distinguish between glaucoma and pituitary macroadenoma by optic disc appearance. METHODS: This prospective case-control study comprised 31 patients: 23 with glaucoma (18 male, 5 female) and 8 with pituitary macroadenoma and chiasmatic compression (3 male, 5 female). The corresponding mean ages were 72.8 years (range 58-90) and 60.7 years (range 43-73). All participants underwent complete ophthalmological examination, spectral domain OCT and OCTA, and visual field testing. Clinical, imaging, and visual field results were compared between the groups. RESULTS: On OCT analysis, the glaucoma group had relatively lower peripapillary retinal nerve fiber layer (RNFL) thickness (65.79 ± 15.46, 86.0 ± 11.37, respectively, P = .002) and lower rim area (1.00 ± 0.22 mm2 and 1.2 ± 0.15 mm2, respectively, P = .005). On OCTA, peripapillary vessel density was significantly lower in all quadrants in the glaucoma group. The significance of these between-group differences was maintained when patients were stratified by visual field mean deviation. CONCLUSIONS: This is the first comparative analysis of optic disc morphology between glaucoma and pituitary macroadenoma using combined OCT and OCTA. The results yielded lower peripapillary RNFL thickness, lower rim area, and lower peripapillary vessel density in the glaucoma group. These parameters may aid in the initial differentiation between these two optic neuropathies.

Elevated intraocular pressure in children with acute lymphoblastic leukaemia: A prospective study.

Most childhood acute lymphoblastic leukaemia (ALL) protocols include high-dose steroid therapy. However, the known potential of high-dose steroids to significantly elevate intraocular pressure (IOP) and lead to glaucomatous optic neuropathy has not been intensively investigated in children with ALL. Moreover, as children with ALL do not routinely undergo IOP measurements, the need for IOP monitoring and therapy is unknown. We prospectively measured IOP in 90 children with newly diagnosed ALL attending a tertiary paediatric haematology/oncology centre, at diagnosis and at the middle and end of induction therapy. Ocular hypertension (IOP > 21 mm Hg) at any time point was documented in 64 children (71%), and the prevalence increased during induction. Thirty-six children (40%) had elevated IOP at ALL diagnosis before therapy initiation, and stratification to non-standard ALL was a risk factor. IOP reduction therapy was administered to 13 children (14%); none required surgery. Values normalised in all cases. On multivariate logistic regression analysis, dexamethasone therapy was a significant risk factor for ocular hypertension. High body mass index was an additional risk factor in children with elevated IOP at ALL diagnosis. Routine evaluation of IOP during steroid therapy is very important in children with ALL to ensure early intervention which may prevent permanent ocular damage.

Efficacy and safety data for the Ab interno XEN45 gel stent implant at 3 Years: A retrospective analysis.

PURPOSE: To report efficacy and safety measures of the XEN45 gel stent at 36 months in the UK National Health Service setting. METHODS: Retrospective non-comparative audit of the records of patients who underwent XEN45 implantation between June 2015 and May 2017 was performed. Main outcome measures were intraocular pressure and number of antihypertensive medications used. Failure was defined as need for further surgery or stent removal. Success was defined as a 20% decrease in intraocular pressure without the need for additional glaucoma medications or a reduction in antihypertensive medications without an increase in baseline intraocular pressure. Needling rates and preoperative factors effect were assessed. RESULTS: The cohort included 205 patients (205 eyes) with primary open angle glaucoma (84.4%), angle closure glaucoma (7.8%), or refractory glaucoma (7.8%), 62.9% had a stand-alone procedure and 37.1%, a combined phaco-XEN45 procedure. Mean intraocular pressure was 22.6 ± 7.0 mmHg at baseline compared to 14.7 ± 3.8 mmHg at 24 months and 14.0 ± 2.9 mmHg at 36 months (p < 0.001 for both). Mean number of medications used was 2.6 ± 1.1 at baseline compared to 0.5 ± 0.9 and 0.6 ± 1.0, at 24- and 36-months, respectively (p < 0.001 for both). The failure rate at 36 months was 25%. Needling was required in 36.6%. Evaluation of background factors yielded an increased failure rate in non-Caucasians compared to Caucasians (74% vs 21%, p < 0.001). CONCLUSION: XEN45 implantation is effective and safe at 36 months' follow-up. Patients should be advised regarding the risk of failure and possible need for bleb revisions. Careful patient selection may be required.

Should every candidate for cataract extraction be scheduled to the preoperative clinic? The Rabin Medical Center experience.

BACKGROUND: Cataract surgery is one of the most common elective surgeries. We present a novel approach of preoperative triage using community-based ophthalmologist referral letters for scheduling surgery, thus reducing both patient and physician time prior to surgery. Since most patients are not routinely examined in a preoperative clinic, day of surgery cancelations are a possibility. The aim of this study is to evaluate the efficiency of our triage system. METHODS: Historical prospective study in which the end point was day-of-surgery cancelation. The main outcome measure of this study was the rate of cancelations which could have been prevented by a preoperative visit. Patients' records were reviewed for reasons for cancelation and demographics. RESULTS: During the study period, 1030 patients underwent cataract surgery, 171 patients (16.6%) were examined in the preoperative clinic. Forty-five patients (4.4%) were canceled on the day of surgery due to various reasons. The main reason for cancelation (13 cases, 28.9%) was non-availability of operating theater. In 20 cases (1.9% of total patients, 44.4% of cancelations), the cancelations could have been prevented by a preoperative clinic visit. CONCLUSION: Our results suggests that most cataract patients do not require preoperative visit prior to the day of surgery. The cooperation of community-based ophthalmologists and the availability of senior surgeons in the operating theater allows for the proper implementation of our system. Direct referral to surgery could shorten both costs and time to surgery and provide timely treatment for cataracts in a cost-aware environment.

Efficacy and safety data for the XEN45 implant at 2 years: a retrospective analysis.

AIM: To report efficacy and safety measures for XEN45 in a National Health Service setting after 24-month follow-up. METHODS: This is a retrospective, non-comparative audit of records of patients who underwent XEN45 procedure between June 2015 and May 2017. The main outcome measures were intraocular pressure (IOP) reduction and number of antihypertensive medications at each timepoint. Failure was defined as requiring further surgery or removal of XEN. Success was defined as 20% reduction of IOP without additional glaucoma medications or reduction in antihypertensive medications without increase in baseline IOP. Needling rates were assessed and subgroup analysis was performed. RESULTS: A total of 151 eyes were included in the study. The main diagnoses were primary open angle glaucoma (84.1%), angle closure glaucoma (8.6%) and refractory glaucoma (7.3%). Stand-alone procedure was performed in 62.3% and combined phaco-XEN was done in 37.7%. The mean IOP at baseline was 22.1±6.5 mm Hg, and the mean IOP at 12 and 24 months was 15.4±5.9 mm Hg and 14.5±3.3 mm Hg, respectively (p<0.001). The mean number of medications was 2.77±1.1 at baseline, and 0.3±0.7 and 0.5±1.0 medications at 12 and 24 months, respectively (p<0.001). 25% of patients failed at the 24-month timepoint. Needling was required in 37.7% of patients at 24 months. Non-Caucasian ethnicity was found to be related to higher failure rate. No significant adverse events were noted. CONCLUSION: XEN45 is a viable, effective and safe procedure after 2 years of follow-up. Patients should be advised regarding failure rate as well as possible need for bleb revisions and medication use.

CyPass® Micro-Stent Safety and Efficacy at One Year: What Have We Learned?

PURPOSE: The suprachoroidal pathway can potentially provide a viable target for intraocular pressure (IOP) control. We present efficacy and safety result for the CyPass® Micro-Stent that provides insight into the use of the suprachoroidal space for IOP reduction. MATERIALS AND METHODS: A retrospective, noncomparative audit of patient records in a university-affiliated National Health Service (NHS) hospital between June 2017 and August 2018. Main outcome measures were IOP reduction and the number of glaucoma drops taken at each time point. Failure and adverse events were noted for each patient. RESULTS: Seventy-seven consecutive case records of 69 patients underwent the CyPass® procedure between August 2017 and August 2018. A stand-alone procedure was performed in 37 (58%) of cases and combined phacoemulsification and CyPass® procedures were performed in 27 (42%) of cases. At baseline, the mean IOP was 24.6 ± 7.2 mm Hg. The mean IOP at 12 months' follow-up was 16.4 ± 4.5 mm Hg (p < 0.05). At baseline, the mean number of medications was 2.41 ± 0.98, which decreased at 12 months to 1.1 ± 1.3 (p < 0.05). Best corrected visual acuity analysis did not show statistically significant change preoperatively and at each postoperative time point. At 12 months' postoperative time point, 24% of eyes had failed. Significant IOP spikes were noted in 18 (28.1%) of cases. CONCLUSION: The suprachoroidal pathway appears to potentially offer an alternative to the classic subconjunctival pathways, yet present a new set of challenges. Further studies would have to address these concerns of endothelial cell loss, IOP spikes, and high failure rate. HOW TO CITE THIS ARTICLE: Gabbay IE, Ruben S. CyPass® Micro-Stent Safety and Efficacy at One Year: What Have We Learned? J Curr Glaucoma Pract 2019;13(3):99-103.

Resolution of recalcitrant chronic papillary conjunctivitis associated with epiphora following punctoplasty and lacrimal stenting.

OBJECTIVE: To assess the use of lacrimal stenting for chronic papillary conjunctivitis associated with epiphora in young adults with little or no atopic background. METHODS: A retrospective interventional case series of 21 consecutive patients (36 eyes) treated for epiphora and chronic papillary conjunctivitis at a tertiary university-affiliated medical center between January 2014 and August 2015 by the same oculoplastic surgeon (I.A). Data were collected by retrospective file review. Patients with a history of ocular disease were excluded from the study. Treatment modalities included lacrimal stenting, punctoplasty, and conservative topical medication. The main outcome measure was post-treatment presence of epiphora and conjunctivitis. RESULTS: Mean patient age was 40 ± 11 years; 86% of patients were female. Fifteen (72%) had bilateral disease. Mean follow-up time was 3.9 ± 1.7 months. Delayed tear clearance as well as a patent lacrimal apparatus were noted in all eyes. No apparent cause of the symptoms was found in any of the eyes. In 12 of the 13 patients (92%) who underwent tube or stent placement, the conjunctivitis and epiphora resolved. In the remainder, symptoms resolved bilaterally in only 1 of 4 patients (25%) who underwent punctoplasty and in only 1 of 4 patients (25%) treated conservatively. CONCLUSION: Recalcitrant papillary conjunctivitis improves following nasolacrimal stenting. Further studies are needed using a prospective controlled design and longer follow-up time.

Cardio-vascular reserve index (CVRI) during exercise complies with the pattern assumed by the cardiovascular reserve hypothesis.

OBJECTIVES: The Cardio-vascular reserve index (CVRI) had been empirically validated in diverse morbidities as a quantitative estimate of the reserve assumed by the cardiovascular reserve hypothesis. This work evaluates whether CVRI during exercise complies with the cardiovascular reserve hypothesis. DESIGN: Retrospective study based on a database of patients who underwent cardio-pulmonary exercise testing (CPX) for diverse indications. METHODS: Patient's physiological measurements were retrieved at four predefined CPX stages (rest, anaerobic threshold, peak exercise and after 2min of recovery). CVRI was individually calculated retrospectively at each stage. RESULTS: Mean CVRI at rest was 0.81, significantly higher (p<0.001) than at all other stages. CVRI decreased with exercise, reaching an average at peak exercise of 0.35, significant lower than at other stages (p<0.001) and very similar regardless of exercise capacity (mean CVRI 0.33-0.37 in 4 groups classified by exercise capacity, p>0.05). CVRI after 2min of recovery rose considerably, most in the group with the best exercise capacity and least in those with the lowest exercise capacity. CONCLUSIONS: CVRI during exercise fits the pattern predicted by the cardiovascular reserve hypothesis. CVRI decreased with exercise reaching a minimum at peak exercise and rising with recovery. The CVRI nadir at peak exercise, similar across groups classified by exercise capacity, complies with the assumed exhaustion threshold. The clinical utility of CVRI should be further evaluated.

The approximated cardiovascular reserve index complies with haemorrhage related hemodynamic deterioration pattern: A swine exsanguination model.

BACKGROUND: To estimate the cardiovascular reserve we formulated the Cardiovascular Reserve Index (CVRI) based on physiological measurements. The aim of this study was to evaluate the pattern of CVRI in haemorrhage-related haemodynamic deterioration in an animal model simulating combat injury. METHODS: Data were collected retrospectively from a research database of swine exsanguination model in which serial physiological measurements were made under anesthesia in 12 swine of haemorrhagic injury and 5 controls. We calculated the approximated CVRI (CVRIA). The course of haemodynamic deterioration was defined according to the cumulative blood loss until shock. The ability of heart rate (HR), mean arterial blood pressure (MABP), stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR) and the CVRIA to predict haemodynamic deterioration was evaluated according to three criteria: strength of association with the course of haemodynamic deterioration (r2 > 0.5); threshold for haemodynamic deterioration detection; and range at which the parameter remained consistently monotonous course of deterioration. RESULTS: Three parameters met the first criterion for prediction of haemodynamic deterioration: HR (r2 = 0.59), SV (r2 = 0.57) and CVRIA (r2 = 0.66). Results were negative for MABP (r2 = 0.27), CO (r2 = 0.33) and SVR (r2 = 0.02). The detection threshold of the CVRIA was 200-300 ml blood loss whereas HR, SV and CO showed a delay in detection, MABP and CVRI exhibited a wide indicative range toward shock. CONCLUSIONS: The CVRIA met preset criteria of a potential predictor of haemorrhage-related haemodynamic deterioration. Prospective studies are required to evaluate use of the CVRI in combat medicine. LEVEL OF EVIDENCE: Level III.

Diabetic foot cellular hypoxia may be due to capillary shunting--a novel hypothesis.

Diabetic foot is traditionally attributed to a triad of neuropathy, ischemia and infection. Cellular hypoxia in diabetic foot can neither be attributed to an occlusive large artery disease (which are mostly patent) nor to the so called diabetic small vessel disease (where such occlusion was never proved). The physiological findings that accompany cellular hypoxia are confusing: elevated local blood flow and high oxygen saturation in both the tissue and its collecting veins. It is well known that some tissues (e.g. skin) are wired with two types of capillaries: True capillaries - also known as exchange capillaries, where nutrients and gases exchange takes place, and metarteriole thoroughfare channels - also known as shunting capillaries. We hypothesize that in the diabetic foot tissue blood flow is rerouted through the metarteriole thoroughfare channel, bypassing the exchange capillaries. Hence, nutrient and gas exchange is disabled and tissue cells became hypoxic regardless of the tissue blood flow. As a result of the shunt, arterial oxygen is not consumed and the oxygen saturation in the collecting veins remains high. The hereby hypothesis suggests that mal-perfusion rather than hypo-perfusion is the underlying cause of cellular hypoxia in diabetic foot. This hypothesis complies with the findings of patent arteries proximal to the affected site, normal to elevated tissue blood flow and high oxygen saturation in the affected tissue and its collecting veins.

Novel surgical performance evaluation approximates Standardized Incidence Ratio with high accuracy at simple means.

BACKGROUND: Excess adverse events may be attributable to poor surgical performance but also to case-mix, which is controlled through the Standardized Incidence Ratio (SIR). SIR calculations can be complicated, resource consuming, and unfeasible in some settings. This article suggests a novel method for SIR approximation. METHODS: In order to evaluate a potential SIR surrogate measure we predefined acceptance criteria. We developed a new measure - Approximate Risk Index (ARI). "Number Needed for Event" (NNE) is the theoretical number of patients needed "to produce" one adverse event. ARI is defined as the quotient of the group of patients needed for no observed events Ge by total patients treated Ga. Our evaluation compared 2500 surgical units and over 3 million heterogeneous risk surgical patients that were induced through a computerized simulation. Surgical unit's data were computed for SIR and ARI to evaluate compliance with the predefined criteria. Approximation was evaluated by correlation analysis and performance prediction capability by Receiver Operating Characteristics (ROC) analysis. RESULTS: ARI strongly correlates with SIR (r(2) = 0.87, p < 0.05). ARI prediction of excessive risk revealed excellent ROC (Area Under the Curve > 0.9) 87% sensitivity and 91% specificity. DISCUSSION AND CONCLUSIONS: ARI provides good approximation of SIR and excellent prediction capability. ARI is simple and cost-effective as it requires thorough risk evaluation of only the adverse events patients. ARI can provide a crucial screening and performance evaluation quality control tool. The ARI method may suit other clinical and epidemiological settings where relatively small fraction of the entire population is affected.

Obesity plays an independent worsening modifying effect on nocturnal hypoxia in obstructive sleep apnea.

OBJECTIVE: Obesity's association with obstructive sleep apnea syndrome (OSAS) is well established. The aim of this study was to examine the impact of obesity on nocturnal hypoxia. METHODS: Twenty two thousand seven hundred and ninety three patients aged 21-80 years who underwent whole night polysomnography during 2000-2009 were included in the study. For each patient, percent sleep time spent with oxyhemoglobin desaturation lower than 90% was calculated (%NODP). Nocturnal hypoxia was analyzed by gender, age, OSAS severity, and body mass index (BMI) categories. RESULTS: Nocturnal hypoxia was positively correlated with BMI, OSAS severity, and age, but not with gender. The differences in %NODP between the two obese groups and non-obese varied from 0.55% to more than a 20% increase and were correlated with age and OSAS severity. The %NODP ratio between the two obese groups and the non-obese was independent of age and OSAS severity. There was a nearly twofold increase in %NODP in obese patients and a threefold increase in the morbidly obese relative to the non-obese. CONCLUSIONS: Our results indicate that obesity plays an independent worsening modifying effect on nocturnal hypoxia in OSAS.

Age- and gender-related characteristics of obstructive sleep apnea.

PURPOSE: The present study attempted to characterize the phenotype of men and women of different ages with a laboratory diagnosis of obstructive sleep apnea (OSA) using demographic, subjective complaints and medical history and to determine the best fitting apnea-hypopnea index (AHI) cutoff point for OSA diagnosis in each group. METHODS: Data collected from 23,806 patients examined by a whole-night polysomnography were retrospectively analyzed. First, descriptive analysis was used to determine the gender-specific relationship between AHI and age, then binary logistic regression was used to determine the best fitting gender- and age-specific AHIs and the predictors of OSA in each age and gender group. RESULTS: Of the total number of patients, 70.7% had AHI >10, and men had consistently higher AHI than women. OSA severity rose linearly with age in normal-weight and obese women and in normal-weight men. The best fitting AHI cutoff point increased with age in both genders. Obesity and snoring were significant predictors of OSA in all age by gender groups, while hypertension and excessive daytime sleepiness were common to all men and the two older women groups. Insomnia-related complaints were negative predictors of obstructive sleep apnea syndrome (OSAS) in some of the groups. CONCLUSIONS: OSAS severity varies with age in both genders, while women have less severe syndrome in all ages. Obesity, snoring, hypertension, and excessive daytime sleepiness are OSAS predictors in both genders, while insomnia-related complaints are negative predictors.