Visual Outcomes and Risk of Endophthalmitis in Open Globe Injuries without Intraocular Foreign Bodies with Delayed Repair.

OBJECTIVE: To assess and compare the rate of endophthalmitis and visual outcomes in cases of OGI's without intraocular foreign bodies repaired within and greater than 24 hours from the time of injury. DESIGN: A retrospective review of 2,002 cases of OGI's presenting to a single institution. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: Patients with OGI's were admitted and managed according to a standardized protocol. METHODS, INTERVENTION, OR TESTING: The impact of timing of repair was assessed between those undergoing OGI repair within (i) 24 hours, (ii) 25-36 hours, and (iii) greater than 36 hours from the time of injury. MAIN OUTCOME AND MEASURE: Rates of endophthalmitis and postoperative visual acuity of logMAR 1.3, logMAR 1.0, and logMAR 0.3 at 180 days and 1 year following open globe repair. RESULTS: 1,382 patients with OGI's were included, of which 75% were male with an average age of 41 years. Maximal zone of injury was zone 1 for 468 patients, zone 2 for 529 patients and zone 3 for 508 patients. 84% of all OGI's underwent repair within 24 hours from the time of injury, 9% from 25-36 hours, and 7% greater than 36 hours. Average preoperative visual acuity was hand motion. Risk factors associated with repair performed greater than 36 hours from the time of injury included female sex (p=0.042). Endophthalmitis was associated with time to repair greater than 36 hours (p=0.049) but not with 25-36 hours or zone of injury (p=0.111). Time to repair had no significant impact on visual acuity outcomes. CONCLUSIONS: Although repair of OGI's within 24 hours is the current standard of care, this study found no statistically significant difference in rates of endophthalmitis or visual outcomes in eyes undergoing repair within 24 hours of injury compared to repair extending to 25 to 36 hours . Endophthalmitis rates did increase after 36 hours. We recommend urgent repair of open globe injuries, but in certain circumstances, it may be reasonable to delay repair beyond 24 hours to optimize operating conditions.

A multi-center analysis of visual outcomes following open globe injury.

The purpose of this study was to examine how demographics, etiology, and clinical examination findings are related to visual outcomes in subjects with open globe injury (OGI) across a large and generalizable sample. A retrospective cohort analysis was performed using data collected from the electronic medical records of four tertiary university centers for subjects with OGI presenting from 2018 to 2021. Demographic information, injury mechanisms, clinical exam findings, visual acuity (VA) at presentation and most recent follow-up were recorded. In subjects with bilateral OGIs, only right eyes were included. A modified ocular trauma score (OTS) using presenting VA, the presence of perforating injury, OGI, and afferent pupillary defect was calculated. The risk of subjects' demographic characteristics, ocular trauma etiology, clinical findings and modified OTS on the presence of monocular blindness at follow-up were assessed using univariable and multivariable regression models. 1426 eyes were identified. The mean age was 48.3 years (SD: ± 22.4 years) and the majority of subjects were men (N = 1069, 75.0%). Univariable analysis demonstrated that subjects of Black race were 66% (OR: 1.66 [1.25-2.20]; P < 0.001) more likely to have monocular blindness relative to White race at follow-up. OTS Class 1 was the strongest predictor of blindness (OR: 38.35 [21.33-68.93]; P < 0.001). Based on multivariable analysis, lower OTS category (OTS Class 1 OR: 23.88 [16.44-45.85]; P < 0.001) moderately predicted visual outcomes (R2 = 0.275, P < 0.001). OGI has many risks of poor visual outcome across patient groups that vary by demographic category, mechanism of injury, and clinical presentation. Our findings validate that a modified OTS remains a strong predictor of visual prognosis following OGI in a large and generalizable sample.

Novel all-arthroscopic biceps tenodesis technique incorporated into rotator cuff repair-two hundred cases with minimum 2-year follow-up.

Background: Biceps tendon pathology is a common source of pain in the shoulder. It is frequently seen in conjunction with symptomatic rotator cuff tears. Biceps tendon management during arthroscopic rotator cuff repairs can be achieved via tenodesis with various techniques or tenotomy. Tenodesis of the biceps generally results in less deformity and reduced exertion-related cramping. However, most techniques require the addition of some type of hardware to provide fixation for the biceps tendon, which adds cost, time, and complexity. This study presents a technique for an all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair, requiring no additional hardware. Methods: This study is a retrospective review of data that were prospectively collected for 200 consecutive patients for whom the procedure was performed. Patients were seen postoperatively at 2 weeks, 6 weeks, 4 months, and 6 months and in addition massive rotator cuff repairs were seen at 8 months. Additionally all patients were contacted at a minimum 2-year follow-up to access for the presence deformity, the American Shoulder and Elbow Surgeons (ASES) score, and SANE score. Descriptive statistics and comparisons to known minimal clinical important differences (MCIDs) for the patient recorded outcome measures were recorded. Results: Two hundred patients were included in the study and 152 responded to the telephone interviews. The mean age of the patients at the time of surgery was 65.3 year old (standard deviation ± 9.1, range of 46-84), and the mean postoperative phone interview was 3.2 years postsurgery (standard deviation of ± 1.0, range of 2-5 years). The average ASES score improved from 52.6 to 94.6, which is 3 times greater than the minimal clinical important difference. The average postoperative SANE score was 94. Seven procedures out of the 200 were labeled as failures due to 1 patient's nonsatisfaction with the procedure and 3 for a Popeye deformity and 3 that had a revision RCR. Discussion: The described method of an arthroscopic biceps tenodesis performed with a rotator cuff repair uses no extra hardware, requires minimal additional operative time, and is clinically effective. At a minimum 2-year follow-up, the all-arthroscopic biceps tenodesis in conjunction with a double-row rotator cuff repair resulted in a marked improvement in their ASES score with a 3.5% failure rate. Conclusion: The all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair demonstrated improved clinical outcome, without requiring any additional hardware to tenodese the biceps, at a minimum 2-year follow-up.

Implementation of anterior segment ophthalmic telemedicine.

PURPOSE OF REVIEW: The growing push to integrate telemedicine into ophthalmic practices requires physicians to have a thorough understanding of ophthalmic telemedicine's applications, limitations, and recent advances in order to provide well tolerated and appropriate clinical care. This review aims to provide an overview of recent advancements in the use of ophthalmic telemedicine for anterior segment eye examinations. RECENT FINDINGS: Virtual care for anterior segment evaluation relies on appropriate technology, novel workflows, and appropriate clinical case selection. Recent advances, particularly in the wake of the COVID-19 pandemic, have highlighted the utility of home-based assessments for visual acuity, external evaluation, tonometry, and refraction. Additionally, innovative workflows incorporating office-based testing into virtual care, termed 'hybrid telemedicine', enable high-quality ophthalmic testing to inform clinical decision-making. SUMMARY: Novel digital tools and workflows enable high-quality anterior segment evaluation and management for select ophthalmic concerns. This review highlights the clinical tools and workflows necessary to enable anterior segment telehealth.

Recovery of Vision in Open Globe Injury Patients with Initial No Light Perception Vision.

PURPOSE: To identify clinical characteristics of injured eyes associated with visual recovery in patients with open globe injuries (OGIs) and presenting with no light perception (NLP) vision. DESIGN: Retrospective chart review. SUBJECTS: All patients presenting to Massachusetts Eye and Ear with OGI and NLP vision from January 1999 to March 2022. METHODS: Manual data extraction to collect patient demographic characteristics, preoperative, intraoperative, and postoperative characteristics of OGI injury, laceration versus rupture, history of intraocular surgery, time from injury to repair, timing of vitrectomy, lensectomy, choroidal drainage, and silicone oil placement, visual acuity (VA) at last follow-up, and subsequent B-scan ultrasound findings of retinal detachment, choroidal hemorrhage, vitreous hemorrhage, and disorganized intraocular contents. Patients with >1 week of follow-up and a documented VA at most recent follow-up were included. Exclusion criteria included age <10 years. Multivariable regression was performed. MAIN OUTCOME MEASURES: Visual acuity recovery defined as light perception or better in patients with OGI and initial NLP vision. RESULTS: One hundred forty-seven eyes with NLP vision after OGI were included. Twenty-five (17%) eyes regained vision at last follow-up. The majority of patients recovered light perception vision (n = 15, 60%) followed by 20/500 or better (n = 5, 20%), hand motions (n = 3, 12%), and counting fingers (n = 2, 8%). Most injuries were zone III (n = 102, 69%) and presented with rupture (n = 127, 86%). The mean time from OGI to surgical repair was 0.85 ± 1.7 days. B-scan was obtained in 104 (71%) cases. Pars plana vitrectomy was performed in 9 eyes (6%) with NLP at time of vitrectomy. Disorganized intraocular contents on B-scan (odd ratio, 0.170; 95% confidence interval, 0.042-0.681; P = 0.012) was the only clinical variable significantly associated with visual recovery, corresponding to a lack of visual improvement. CONCLUSIONS: Recovery of vision in OGI with NLP vision at presentation cannot be predicted based on presenting clinical features. B-scan findings of disorganized intraocular contents after initial OGI repair was the only factor negatively associated with vision recovery in this patient population. Therefore, all eyes presenting with an OGI and NLP vision should undergo primary repair in hopes of subsequent visual recovery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Therapeutic potential of berberine in attenuating cholestatic liver injury: insights from a PSC mouse model.

BACKGROUND AND AIMS: Primary sclerosing cholangitis (PSC) is a chronic liver disease characterized by progressive biliary inflammation and bile duct injury. Berberine (BBR) is a bioactive isoquinoline alkaloid found in various herbs and has multiple beneficial effects on metabolic and inflammatory diseases, including liver diseases. This study aimed to examine the therapeutic effect of BBR on cholestatic liver injury in a PSC mouse model (Mdr2-/- mice) and elucidate the underlying mechanisms. METHODS: Mdr2-/-mice (12-14 weeks old, both sexes) received either BBR (50 mg/kg) or control solution daily for eight weeks via oral gavage. Histological and serum biochemical analyses were used to assess fibrotic liver injury severity. Total RNAseq and pathway analyses were used to identify the potential signaling pathways modulated by BBR in the liver. The expression levels of key genes involved in regulating hepatic fibrosis, bile duct proliferation, inflammation, and bile acid metabolism were validated by qRT-PCR or Western blot analysis. The bile acid composition and levels in the serum, liver, small intestine, and feces and tissue distribution of BBR were measured by LC-MS/MS. Intestinal inflammation and injury were assessed by gene expression profiling and histological analysis. The impact on the gut microbiome was assessed using 16S rRNA gene sequencing. RESULTS: BBR treatment significantly ameliorated cholestatic liver injury, evidenced by decreased serum levels of AST, ALT, and ALP, and reduced bile duct proliferation and hepatic fibrosis, as shown by H&E, Picro-Sirius Red, and CK19 IHC staining. RNAseq and qRT-PCR analyses indicated a substantial inhibition of fibrotic and inflammatory gene expression. BBR also mitigated ER stress by downregulating Chop, Atf4 and Xbp-1 expression. In addition, BBR modulated bile acid metabolism by altering key gene expressions in the liver and small intestine, resulting in restored bile acid homeostasis characterized by reduced total bile acids in serum, liver, and small intestine and increased fecal excretion. Furthermore, BBR significantly improved intestinal barrier function and reduced bacterial translocation by modulating the gut microbiota. CONCLUSION: BBR effectively attenuates cholestatic liver injury, suggesting its potential as a therapeutic agent for PSC and other cholestatic liver diseases.

Review of Management and Outcomes of Delayed Repair Open Globe Injuries.

The standard of care for open globe injuries is prompt surgical closure, as delay in repair is a reported risk factor for post-traumatic endophthalmitis and is associated with worse visual outcomes. This article serves as a review of the current management and outcomes of open globe injuries repaired greater than 24 hours from the time of injury, specifically evaluating the rates of endophthalmitis in cases with and without intraocular foreign bodies, visual outcomes and rates of primary enucleation or evisceration.

A Novel Ophthalmic Telemedicine Program for Follow-Up of Minor Ophthalmic Emergencies.

Background: Near-term follow-up for minor ophthalmic emergencies is important to ensure positive patient outcomes but can impose logistical challenges for patients and ophthalmology practices. While ophthalmic telemedicine has been used for screening and triage, its feasibility and safety for follow-up care for minor ophthalmic emergencies have not been reported. The objective of this study was to report initial results of a novel virtual emergency department (ED) follow-up clinic. Methods: Retrospective cross-sectional study of patients discharged from the ophthalmic ED who required near-term follow-up and carried diagnoses suitable for virtual evaluation, between December 6, 2021, and June 26, 2022, at a single tertiary eye care center. Main outcome measures included missed appointment rate, time interval between ED encounter and virtual follow-up, clinical diagnoses, and referrals after telemedicine follow-up (including for urgent ambulatory and ED evaluation). Results: A total of 145 virtual visits were scheduled with 99 (68.3%) completed appointments, yielding a no-show rate of 31.7%. Of the completed visits, the mean time interval between ED evaluation and virtual follow-up was 8.3 days (standard deviation ±3.9). Eighty-four (84.9%) visits were video-based and 15 (15.1%) were audio-only. Seventy-nine (94%) had at least one aspect of the ophthalmic examination documented. The most common diagnoses were chalazion (18), conjunctivitis (13), corneal abrasion (12), and encounter after corneal foreign body removal (7). After virtual follow-up, 23 patients (23.2%) had subsequent referrals, and no patients re-presented to the ophthalmic ED. Conclusions: Ophthalmic telemedicine may be a safe and feasible modality for providing timely post-acute near-term follow-up care for patients with appropriate ophthalmic diagnoses.

Open Globe Injuries From Garage Door Springs.

We describe seven patients who were attempting to repair their garage door when a spring dislodged at high velocity, resulting in open globe injury. All patients were seen at Massachusetts Eye and Ear between the years 2008 and 2023. Their final visual acuities ranged from 20/125 to no light perception. Open globe injury appears to be a risk of attempts to repair a garage door by people who are inexperienced in doing so. [Ophthalmic Surg Lasers Imaging Retina 2023;54:666-669.].

Traumatic rupture of the inferior rectus muscle: case report and review of the literature.

Traumatic inferior rectus muscle rupture secondary to blunt injury in the absence of associated orbital or ocular fractures or injury is rarely encountered, and there are limited published reports on subsequent surgical repair. We present the case of a 74-year-old man with complete inferior rectus transection following a fall with facial strike. A computed tomography scan of the face was unremarkable. Surgical exploration and repair of the muscle was performed by hooking the inferior oblique muscle to identify the inferior rectus muscle. Subsequent strabismus surgery was performed for residual binocular diplopia, resulting in excellent anatomic and visual outcomes and postoperative ocular alignment.

Early Postoperative Magnetic Resonance Imaging Findings Related to Electrocauterization for Cerebellar Reduction During Chiari Decompression Surgery.

BACKGROUND: Cerebellar tonsillar reduction or resection can be performed as part of the surgical management of Chiari type 1 malformation when it is accompanied by symptomatic brainstem compression or syringomyelia. The purpose of this study is to characterize the early postoperative magnetic resonance imaging (MRI) findings in patients with Chiari type 1 malformations who undergo cerebellar tonsillar reduction via electrocautery. METHODS: The extent of cytotoxic edema and microhemorrhages demonstrated on MRI scans obtained within 9 days following surgery was assessed and correlated with neurological symptoms. RESULTS: Cytotoxic edema was found on all postoperative MRI examinations included in this series, with superimposed hemorrhage in 12 of 16 patients (75%) and was primarily located along the margins of the cauterized inferior cerebellum. Cytotoxic edema was present beyond the margins of the cauterized cerebellar tonsils in 5 of 16 patients (31%) and was associated with new focal neurological deficits in 4 of 5 patients (80%). CONCLUSION: Cytotoxic edema and hemorrhages along the cerebellar tonsil cautery margins can be expected findings in early postoperative MRI in patients who undergo Chiari decompression accompanied by tonsillar reduction. However, the presence of cytotoxic edema beyond these regions can be associated with new focal neurological symptoms.

Advances in the Radiological Evaluation of and Theranostics for Glioblastoma.

Imaging is essential for evaluating patients with glioblastoma. Traditionally a multimodality undertaking, CT, including CT cerebral blood profusion, PET/CT with traditional fluorine-18 fluorodeoxyglucose (18F-FDG), and MRI have been the mainstays for diagnosis and post-therapeutic assessment. However, recent advances in these modalities, in league with the emerging fields of radiomics and theranostics, may prove helpful in improving diagnostic accuracy and treating the disease.

Patient and Visit Characteristics Associated With Otolaryngology Telemedicine Care.

BACKGROUND: Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. The degree of health disparities among patients receiving otolaryngologic telemedical care is unclear. AIMS: We performed a retrospective cross-sectional study to explore disparities in telemedicine delivery. METHODS: We evaluated otolaryngology clinical visits from January 2019 to November 2022. We obtained patient demographics and visit characteristics (e.g., subspecialty, telemedicine vs in-person). Our primary outcome was demographic characteristics of otolaryngology patients who received telemedicine vs in-person care during the study timeframe. RESULTS: A total of 231,384 otolaryngology clinical visits were reviewed, of which 26,895 (11.6%) were telemedicine visits. Rhinology (36.5%) and facial plastics (28.4%) subspecialties performed the most telemedicine visits. On multivariate analysis, individuals who identified as Asian, non-English speaking, and with Medicare insurance were statistically significantly less likely to use telemedicine than in-person services. CONCLUSION: Our findings suggest that expanding telemedicine care may not improve access for all populations, and socioeconomic factors are important considerations to ensure patients are receiving equally accessible care. Futures studies are warranted to understand how these disparities may impact health outcomes and patient satisfaction with care.

The Dynamic Role of Endoplasmic Reticulum Stress in Chronic Liver Disease.

Chronic liver disease (CLD) is a major worldwide public health threat, with an estimated prevalence of 1.5 billion individuals with CLD in 2020. Chronic activation of endoplasmic reticulum (ER) stress-related pathways is recognized as substantially contributing to the pathologic progression of CLD. The ER is an intracellular organelle that folds proteins into their correct three-dimensional shapes. ER-associated enzymes and chaperone proteins highly regulate this process. Perturbations in protein folding lead to misfolded or unfolded protein accumulation in the ER lumen, resulting in ER stress and concomitant activation of the unfolded protein response (UPR). The adaptive UPR is a set of signal transduction pathways evolved in mammalian cells that attempts to reestablish ER protein homeostasis by reducing protein load and increasing ER-associated degradation. However, maladaptive UPR responses in CLD occur due to prolonged UPR activation, leading to concomitant inflammation and cell death. This review assesses the current understanding of the cellular and molecular mechanisms that regulate ER stress and the UPR in the progression of various liver diseases and the potential pharmacologic and biological interventions that target the UPR.

MRI radiomics and potential applications to glioblastoma.

MRI plays an important role in the evaluation of glioblastoma, both at initial diagnosis and follow up after treatment. Quantitative analysis via radiomics can augment the interpretation of MRI in terms of providing insights regarding the differential diagnosis, genotype, treatment response, and prognosis. The various MRI radiomic features of glioblastoma are reviewed in this article.

A preliminary diagnostic accuracy study of quantitative MRI biomarkers for differentiating parotid tumor types.

Background: Differentiating among the different types of parotid tumors on imaging is useful for guiding clinical disposition, which ultimately may lead to surgical management. The goal of this study was to determine whether quantitative T2 signal characteristics and morphologic features on magnetic resonance imaging (MRI) can serve as predictive biomarkers for distinguishing between tumor types. Methods: A retrospective review of T2-weighted MRIs in patients with pathology-proven parotid tumors was performed. Quantitative T2 maps and surface regularity measurements of the tumors were obtained via semi-automated regions of interest (ROI). Linear Discriminant Analysis was used to populate the receiver operating characteristics (ROCs) curves for these variables. A P value of <0.05 was considered to be significant. Results: A total of 35 tumors (21 benign and 14 malignant neoplasms) were included in this analysis. For differentiating the benign versus malignant classes of parotid tumors, T2 signal and surface regularity combined yielded an area under the curve of 0.62 (P value: 0.2) through the ROC analysis. However, for the pleomorphic adenomas versus other types of parotid tumors, using both T2 signal and surface regularity yielded an area under the curve of 0.81 (P value: 0.007) through the ROC analysis. Conclusions: T2 signal and surface regularity combined can significantly differentiate pleomorphic adenomas from other types of parotid tumors and can potentially be used as a predictive imaging biomarker.

Effectiveness of a telemedicine program for triage and diagnosis of emergent ophthalmic conditions.

BACKGROUND: To study the utility of a teleophthalmology program to diagnose and triage common ophthalmic complaints presenting to an ophthalmic emergency room. METHODS: Prospective, observational study of 258 eyes of 129 patients presenting to the Massachusetts Eye and Ear Infirmary Emergency Ward (MEE EW) who completed a questionnaire to gather chief complaint (CC), history of present illness, and medical history. Anterior and posterior segment photographs were collected via iPhone 5 C camera and a Canon non-mydriatic fundus camera, respectively. Ophthalmic vital signs were collected. All information was reviewed remotely by three ophthalmologists; a diagnosis and urgency designation were recorded. The remote assessment was compared to gold standard in-person assessment. RESULTS: The 129 recruited patients collectively contributed 220 visual complaints, of which 121 (55%) were from females with mean age 56.5 years (range 24-89). Sensitivities and specificities for telemedical triage were as follows: eye pain (n = 56; sensitivity: 0.58, CI [0.41, 0.74]; specificity: 0.91, CI [0.80, 1]), eye redness (n = 54; 0.68, CI [0.50, 0.86]; 0.93, CI [0.84, 1]), blurry vision (n = 68; 0.73, CI [0.60, 0.86]; 0.91, CI [0.80, 1]), and eyelid complaints (n = 42; 0.67, CI [0.43, 0.91]; 0.96, CI [0.89, 1]). The remote diagnostic accuracies, as stratified by CC, were eye pain (27/56; 48.21%), eye redness: (32/54; 59.26%), blurry vision: (30/68; 44.11%), eyelid (24/42; 57.14%). CONCLUSIONS: Telemedical examination of emergent ophthalmic complaints consisting of a patient questionnaire, anterior segment and fundus photos, and ophthalmic vital signs, may be useful to reliably triage eye disease based on presenting complaint.