A nurse-led, unit-based program to reduce restraint use in acute care.

Although the effectiveness of restraints is not proven, the dangers of restraints are clear. Many advocate for the reduction of restraint use in tertiary care settings. The Joint Commission on the Accreditation of Healthcare Organizations is setting the standard by insisting that hospital administrations create a culture that emphasizes restraint reduction. Despite the importance of this task, very little is available in the literature to direct or guide this effort. The purpose of this article is to describe a unit-based Restraint Reduction Program that was successful on a neurology/neurosurgery unit.

Radiation exposure: a new risk factor for idiopathic perifoveal telangiectasis.

OBJECTIVE: To examine the association between previous radiation exposure and idiopathic perifoveal telangiectasis (IPT). DESIGN: A multicentered, individually matched, case-control study design was used. PARTICIPANTS/CONTROLS: Sixty-five case subjects were matched with 175 control subjects. Individuals with unequivocal evidence of angiographically confirmed IPT were included as cases. Control subjects were matched for center, age, and gender. MAIN OUTCOME MEASURE: The main exposures of interest were a history of therapeutic head or neck irradiation and environmental radiation exposure. METHODS: A standardized questionnaire was administered to case and control subjects. Data were collected for the main exposures of interest as well as pertinent covariates. Conditional logistic regression was used to evaluate therapeutic and environmental radiation as risks for IPT. RESULTS: On univariate analysis, head or neck irradiation was associated with IPT (odds ratios [OR] = 4.15, 95% confidence interval [CI] = 1.30-13.24). While controlling for diabetes and family history of diabetes, IPT was found to be associated with both head or neck irradiation (OR = 4.06, 95% CI = 1.20-13.76) and with environmental irradiation (OR = 6.73, 95% CI = 1.06-42.74). CONCLUSIONS: This study presents a previously unreported association between prior radiation exposure and IPT.

Presumed macular choroidal watershed vascular filling, choroidal neovascularization, and systemic vascular disease in patients with age-related macular degeneration.

PURPOSE: To investigate the possible association of presumed macular choroidal watershed vascular filling (PMWF), choroidal neovascularization, and systemic vascular disease in patients with age-related macular degeneration. METHODS: In a retrospective study, we evaluated 74 randomly selected indocyanine green videoangiograms of 74 patients with age-related macular degeneration. We also reviewed the charts of 20 randomly selected, age-matched control patients without age-related macular degeneration, initially referred for uniocular conditions, and subsequently performed indocyanine green videoangiography on their normal fellow eyes. We evaluated these videoangiograms for the presence of PMWF, manifesting as characteristic early choroidal hypofluorescence and its relation to choroidal neovascularization when present. Additionally, the incidence of hypertension, coronary artery disease, peripheral vascular disease, and diabetes mellitus was determined. RESULTS: Forty-one (55.4%) of 74 patients with age-related macular degeneration vs three (15.0%) of 20 normal control patients exhibited PMWF on indocyanine green videoangiography (P = .0014). Of the 61 patients with age-related macular degeneration and choroidal neovascularization, 36 (59.0%) exhibited PMWF on videoangiography. Associated choroidal neovascularization arose from the PMWF zone in 33 (91.7%) of these cases. Hypertension was observed in 24 (58.5%) of 41 patients with age-related macular degeneration and PMWF vs nine (27.3%) of 33 patients with age-related macular degeneration who did not exhibit PMWF (P = .007). CONCLUSIONS: An increased incidence of PMWF occurs in patients with age-related macular degeneration with a possible predisposition for the development of associated choroidal neovascularization. Additionally, PMWF may be accentuated by associated hypertensive choroidal microvascular insult.

Idiopathic polypoidal choroidal vasculopathy associated with retinal arterial macroaneurysm and hypertensive retinopathy.

BACKGROUND: Idiopathic polypoidal choroidal vasculopathy (IPCV), the posterior uveal bleeding syndrome, and multiple recurrent serosanguineous pigment epithelial detachments in black women are a heterogeneous group of related entities seen in elderly hypertensive females. Similar associations are known for retinal arterial macroaneurysm (RAM). METHODS: This report documents the clinical, fluorescein, and indocyanine green videoangiographic findings of two elderly black female hypertensive patients who presented with IPCV, RAM, and hypertensive retinopathy. RESULTS: Clinical, fluorescein, and indocyanine green videoangiographic analysis of these two patients revealed hypertensive retinopathy, RAM, and anomalous polypoidal vascular networks associated with focal "bead-string" constrictions, terminal vascular loops, and polypoidal and pinpoint choroidal nodules. CONCLUSION: Certain subgroups of IPCV and related entities and RAM may be pathophysiologically related as analogous hypertensive insults to the choroidal and retinal vascular beds.

Indocyanine green angiography in Stargardt's flavimaculatus.

PURPOSE: We studied the indocyanine green videoangiographic characteristics of eyes in patients with Stargardt's flavimaculatus and fluorescein angiographic evidence of a dark choroid. METHODS: Affected individuals underwent ophthalmic examination and fluorescein angiographic examination. Indocyanine green videoangiography was performed on eight patients with classic Stargardt's flavimaculatus. Two additional asymptomatic patients with mild manifestations of Stargardt's flavimaculatus, both of whom were related to one patient with the classic phenotype, were also examined with indocyanine green videoangiography. RESULTS: Choroidal detail was evident in all patients examined with indocyanine green videoangiography, and varying degrees of choroidal vascular closure were documented in the maculas of eight patients. Retinal pigment epithelial flecks were found to block indocyanine green videoangiographic fluoresence progressively. Late indocyanine green videoangiographic imaes frequently showed retinal pigment epithelial involvement in areas of retina thought to be uninvolved clinically and by fluorescein angiography. Peripapillary crescents of hypofluorescence, which in some patients were not noted clinically or by fluorescein angiography, were observed in all ten patients examined with indocyanine green videoangiography. In one asymptomatic patient, retinal pigment epithelial flecks could be identified only with indocyanine green videoangiography. CONCLUSIONS: Indocyanine green videoangiography in conjunction with fluorescein angiography can be a valuable tool in the recognition and further understanding of Stargardt's flavimaculatus.

Use of digitized fluorescein angiogram system to evaluate laser treatment for subretinal neovascularization: technique.

In patients with subretinal neovascular membranes (SRNVM), persistence of the SRNVM after laser treatment is a major cause of decreased visual acuity. Persistence is associated with inadequate initial laser treatment. A technique using a digitized fluorescein angiogram (DFA) system is presented that allows immediate evaluation of the adequacy of laser treatment for SRNVM. This involves overlaying a red-free photograph taken after treatment on a fluorescein angiogram taken before treatment using a digital angiogram system that evaluates the adequacy of treatment. A protocol for augmentation of laser treatment has been developed that will aid in the reduction of persistence after laser treatment of SRNVM.

Evaluation of persistence of subretinal neovascular membranes using digitized angiographic analysis.

A study was conducted using the digitized fluorescein angiogram (DFA) system to evaluate adequacy of coverage of laser treatment for subretinal neovascular membranes (SRNVM) and to confirm that complete coverage lowers the incidence of persistent SRNVMs. Ten consecutive cases were evaluated with the DFA system after undergoing a single laser treatment. Three cases were judged to be adequately treated, and the remaining seven cases were judged to be inadequately treated. The DFA system was then used during photocoagulation in 16 consecutive cases to verify complete coverage of the SRNVM or to indicate the need for photocoagulation augmentation. Despite augmentation, 2 of the 16 cases remained inadequately treated. Overall, the cases that were adequately treated had a 12% (2/17) persistence rate, whereas those that were inadequately treated had a persistence rate of 67% (6/9). The data indicate that adequate coverage of SRNVMs is essential to prevent persistence.

Surgical intervention for combined retinal-retinal pigment epithelial hamartoma.

A young woman was followed for over 20 years with a macular combined hamartoma of the retina and retinal pigment epithelium. When vision deteriorated due to contracture of an overlying epiretinal membrane, a pars plana vitrectomy with removal of the membrane was performed. Decreased vascular tortuosity and retinal vascular leakage resulted in postoperative improvement of visual acuity. Selected patients with combined retinal and retinal pigment epithelial hamartomas may benefit from removal of epiretinal membranes.

Acute leukemia presenting as a unilateral exudative retinal detachment.

The leukemias commonly involve the eyes and adnexae. It is unusual, however, for leukemia to present with visual complaints. Furthermore, there are only rare case reports of leukemic patients presenting with bilateral exudative retinal detachments. We report a unique case of a boy who presented with visual loss due to a unilateral exudative retinal detachment. A systemic evaluation discovered acute lymphocytic leukemia (ALL). There was rapid settling of the exudative detachment and improvement in vision while the patient received chemotherapy and radiotherapy for the ALL.

Retinal and choroidal vascular occlusion secondary to corticosteroid embolisation.

We report a case of visual loss following intranasal injection of triamcinolone acetonide and phenylephrine hydrochloride in a 22-year-old female with chronic sinusitis. Clinical examination and fluorescein angiography revealed vascular occlusions which involved multiple small branches of both the choroidal and retinal circulations. The mechanism of such a complication probably involves inadvertent intra-arterial injection into the anterior or the posterior ethmoidal artery, with retrograde flow into the opthalmic arterial system. Precautions can be taken to avoid such complications.

Inherited retinal venous beading.

Four affected family members in two generations demonstrated an unusual, probably autosomal dominant, retinal vascular disorder called inherited retinal venous beading. The proband had retinal neovascularization, exudation, and vitreous hemorrhage. The other three affected family members had significant venous beading and varying degrees of arteriolar tortuosity. Family members with venous beading had low to normal leukocyte and neutrophil counts, which differed significantly from unaffected family members.

Ocular complications associated with retrobulbar injections.

The authors describe six complications, of retrobulbar injections documented by fundus photography and fluorescein angiography. These include (1) injection of corticosteroid into the posterior ciliary arterial circulation resulting in emboli in the vasculature of the choroid and the optic nerve head; (2) injection of corticosteroid into the ophthalmic artery resulting in emboli in both the choroidal and retinal circulations; (3) presumed injection of lidocaine and air into the optic nerve sheath adjacent to the globe with extension anteriorly into the subretinal space and the space between the posterior vitreous and the internal limiting membrane; (4) occlusion of the central retinal artery without an associated retrobulbar hemorrhage; (5) trauma to and partial injection of lidocaine in the central retinal artery with embolization into the retinal circulation; and (6) presumed injection of lidocaine into the optic nerve sheath producing a combined central retinal vein and artery occlusion. Alternative techniques that might decrease the incidence of complications associated with retrobulbar injections are discussed.

Choroidal neovascularization associated with choroidal nevi.

We observed choroidal neovascularization with associated macular detachment in three cases of benign choroidal nevi. Successful obliteration of the neovascular membranes was performed with argon laser photocoagulation with maintenance of good central visual acuity.