Haptic curing with endolaser after lens tilt in the Yamane technique.

Purpose: To describe a case of intraocular lens (IOL) tilt following transscleral IOL fixation with the Yamane technique and subsequent correction of tilt using 810-nm endoscopic diode laser. Observations: Our patient required lens exchange and secondary IOL implantation due to a dislocated 1-piece IOL in the bag causing iris chafe. After routine IOL fixation with the Yamane technique and a Zeiss CT Lucia 602 lens, the IOL tilted significantly in the immediate postoperative period. The lens tilt was subsequently corrected in the operating room using endolaser to melt and reshape (cure) the optic-haptic junction. Conclusions: IOL tilt is a known complication associated with the Yamane technique, which has seen increasing reports with the Zeiss CT Lucia 602 lens. Using endolaser to reconfigure the tilted optic into the desired orientation is a more novel procedure that can correct the lens tilt without the need for IOL exchange.

Five-Year Cost-Effectiveness Modeling of Primary Care-Based, Nonmydriatic Automated Retinal Image Analysis Screening Among Low-Income Patients With Diabetes.

BACKGROUND: Artificial intelligence-based technology systems offer an alternative solution for diabetic retinopathy (DR) screening compared with standard, in-office dilated eye examinations. We performed a cost-effectiveness analysis of Automated Retinal Image Analysis System (ARIAS)-based DR screening in a primary care medicine clinic that serves a low-income patient population. METHODS: A model-based, cost-effectiveness analysis of two DR screening systems was created utilizing data from a recent study comparing adherence rates to follow-up eye care among adults ages 18 or older with a clinical diagnosis of diabetes. In the study, the patients were prescreened with an ARIAS-based, nonmydriatic (undilated), point-of-care tool in the primary care setting and were compared with patients with diabetes who were referred for dilated retinal screening without prescreening, as is the current standard of care. Using a Markov model with microsimulation resulting in a total of 600 000 simulated patient experiences, we calculated the incremental cost-utility ratio (ICUR) of the two screening approaches, with regard to five-year cost-effectiveness of DR screening and treatment of vision-threatening DR. RESULTS: At five years, ARIAS-based screening showed similar utility as the standard of care screening systems. However, ARIAS reduced costs by 23.3%, with an ICUR of $258 721.81 comparing the current practice to ARIAS. CONCLUSIONS: Primary care-based ARIAS DR screening is cost-effective when compared with standard of care screening methods.

Assessing the Clinical Requirement of 2.5% Phenylephrine for Diagnostic Pupil Examination.

Purpose: To evaluate whether the standard dilating drop regimen consisting of phenylephrine, tropicamide, and proparacaine produces clinically significant improvement in pupil size compared to tropicamide and proparacaine during diagnostic eye examination. Methods: Sixty-three adult patients at Washington University School of Medicine Eye Clinic were enrolled in this prospective, randomized trial. Each patient received one of two dilating drop regimens: phenylephrine + tropicamide + proparacaine (PE+T+PP), which is considered the standard therapy, or tropicamide + proparacaine (T+PP). Main outcome measures were the proportion of pupils able to achieve successful clinical examination without need for additional dilating drops and change in predilation to postdilation pupil size. Comparisons were made using McNemar's test, repeated measures analysis of variance, and Fisher's test to determine whether PE is a necessary component of the standard eye examination. Results: There were no statistically significant differences between the PE+T+PP and T+PE treatment groups in predilation to postdilation changes in average resting pupil size (1.58 ± 0.66 and 2.61 ± 0.79; P = 0.57) or constricted pupil size (2.52 ± 0.93 and 3.56 ± 0.96; P = 0.15). There was no statistically significant difference between patients who obtained a successful dilated pupil examination between those receiving PE+T+PP and those receiving T+PP as determined by the examining physicians (Fisher's, P = 0.67). Conclusion: The addition of phenylephrine to tropicamide and proparacaine did not improve pupillary dilation size or ability to conduct a clinical examination. A single dilating agent using tropicamide should be considered in clinical practice.

Factors Associated with Adherence to Screening Guidelines for Diabetic Retinopathy Among Low-Income Metropolitan Patients.

In this retrospective analysis of patients with diabetes in an academic primary care clinic in St. Louis, attendance at ophthalmic screening appointments was recorded over a two-year observation window. Factors associated with adherence were analyzed by multivariable regression. Among 974 total patients included, only 330 (33.9%) were adherent within a two-year period. Multivariate analyses identified older age, female gender, primary language other than English, and attendance at ancillary diabetes clinic visits as factors associated with improved diabetic retinopathy screening adherence. Factors not associated with adherence included race and insurance status.

Intraoperative suprachoroidal hemorrhage during Xen gel stent implantation.

PURPOSE: To report a rare case of intraoperative suprachoroidal hemorrhage during Xen gel stent implantation with accompanying surgical video and subsequent 6-month follow-up. OBSERVATIONS: Our patient required incisional glaucoma surgery after inadequate pressure reduction with four classes of topical medication, methazolamide, and selective laser trabeculoplasty. The patient underwent Xen gel stent implantation and developed an intraoperative suprachoroidal hemorrhage, which was managed in the operating room. The patient recovered his baseline visual acuity with a functioning bleb out to 6 months postoperatively. CONCLUSIONS AND IMPORTANCE: Micro-invasive glaucoma surgeries offer a new repertoire of surgical options, purportedly with safer and less invasive techniques. Xen gel stent implantation may be a promising alternative to traditional trabeculectomies and tube shunt implants, providing similar IOP lowering results with potentially lower risk for complications. However, rare and severe complications such as suprachoroidal hemorrhage may still occur. Recognizing a suprachoroidal bleed, particularly intraoperatively, will still be necessary to help minimize the potential vision threatening sequelae often associated with this severe complication.

Evaluation of Skyshine from an Accelerator Facility: Dependence on Distance and Angle.

Neutron skyshine from Linac Coherent Light Source II 4 GeV electron beam operation at SLAC National Accelerator Laboratory can contribute to prompt radiation exposure to the public at distances far beyond the accelerator tunnel housing. One of the shielding design requirements at SLAC is that the annual dose to a member of the public is no more than 0.05 mSv y. This study uses Monte Carlo code FLUKA to simulate the generation of neutrons from 4 GeV electron beam losses on a thick copper target inside a generalized geometry of the Linac Coherent Light Source II Beam Transport Hall accelerator tunnel section. The effective dose from neutron skyshine was characterized as a function of both distance from the tunnel wall (up to 1 km away) and angle relative to the beam direction (between 0° and 180°). This new methodology for evaluating neutron skyshine dose is applicable to high-energy GeV-range electron accelerator facilities both at SLAC and elsewhere.

Depsipeptide Aspergillicins Revealed by Chromatin Reader Protein Deletion.

Expression of biosynthetic gene clusters (BGCs) in filamentous fungi is highly regulated by epigenetic remodeling of chromatin structure. Two classes of histone modifying proteins, writers (which place modifications on histone tails) and erasers (which remove the modifications), have been used extensively to activate cryptic BGCs in fungi. Here, for the first time, we present activation of a cryptic BGC by a third category of histone modifying proteins, reader proteins that recognize histone tail modifications and commonly mediate writer and eraser activity. Loss of the reader SntB (Δ sntB) resulted in the synthesis of two cryptic cyclic hexa-depsipeptides, aspergillicin A and aspergillicin F, in the fungus Aspergillus flavus. Liquid chromatography, high resolution mass spectrometry, and NMR analysis coupled with bioinformatic analysis and gene deletion experiments revealed that a six adenylation (A) domain nonribosomal peptide synthetase (NRPS, called AgiA) and O-methyltransferase (AgiB) were required for metabolite formation. A proposed biosynthetic scheme illustrates the requirement for unusual NRPS domains, such as a starting condensation domain and a thiolesterase domain proposed to cyclize the depsipeptides. This latter activity has only been found in bacterial but not fungal NRPS. The agi BGC-unique to A. flavus and some closely related species (e.g., A. oryzae, A. arachidicola)-is located next to a conserved Aspergillus siderophore BGC syntenic to other fungi.

Intranasal Corticosteroids Do Not Lead to Ocular Changes: A Systematic Review and Meta-analysis.

OBJECTIVES: The safety and efficacy of intranasal corticosteroids (INCS) are well established, but there remains apprehension that INCS could lead to systemic side effects, as with oral steroids. The objective of this systematic review was to assess whether the use of INCS lead to increased intraocular pressure (IOP) above 20 mm Hg, glaucoma, or formation of posterior subcapsular cataracts in adult patients with rhinitis. METHODS: Two medical librarians searched the published literature for records discussing the use of "nasal steroids" in "rhinitis" and their effect on "intraocular pressure," "cataracts," or "glaucoma." RESULTS: A total of 484 studies were identified, and 10 randomized controlled trials met our inclusion criteria. Meta-analysis of 2,226 patients revealed that the relative risk of elevated IOP in those who received INCS was 2.24 (95% confidence interval [CI]: 0.68 to 7.34) compared to placebo. The absolute increased incidence of elevated IOP in patients using INCS compared to placebo was 0.8% (95% CI: 0% to 1.6%). There were zero cases of glaucoma in both placebo and INCS groups at 12 months. The absolute increased incidence of developing a posterior subcapsular cataract was 0.02% (95% CI: -0.3% to 0.4%). CONCLUSIONS: Use of INCS is not associated with a significant risk of elevating IOP or developing a posterior subcapsular cataract in patients with allergic rhinitis. Presence of glaucoma, however, is the real clinical adverse event of concern. There were zero reported cases of glaucoma at 12 months. Future studies should formally evaluate for glaucoma rather than use IOP measures as a surrogate. Laryngoscope, 129:6-12, 2019.

Radiation Protection Around High-intensity Laser Interactions with Solid Targets.

Interaction of a high-intensity optical laser with a solid target can generate an ionizing radiation hazard in the form of high-energy "hot" electrons and bremsstrahlung, resulting from hot electrons interacting with the target itself and the surrounding target chamber. Previous studies have characterized the bremsstrahlung dose yields generated by such interactions for lasers in the range of 10 to 10 W cm using particle-in-cell code EPOCH and Monte Carlo code FLUKA. In this paper, electron measurements based on a depth-dose approach are presented for two laser intensities, which indicate a Maxwellian distribution is more suitable for estimating the hot electrons' energy distribution. Also, transmission factors for the resulting bremsstrahlung for common shielding materials are calculated with FLUKA, and shielding tenth-value-layer thicknesses are also derived. In combination with the bremsstrahlung dose yield, the tenth-value layers provide radiation protection programs the means to evaluate radiation hazards and design shielding for high-intensity laser facilities.

Assessing the utility of 2.5% phenylephrine for diagnostic pupillary dilation.

OBJECTIVE: To evaluate whether the addition of phenylephrine to tropicamide produces any clinically significant change in pupil size during diagnostic eye examination. METHODS: Twenty healthy adults at the Washington University School of Medicine Eye Clinic were enrolled in this prospective, nonrandomized, crossover trial. Each had 3 dilating eye drop regimens administered to the left eye on separate days. Tropicamide (T) + proparacaine (PP) + phenylephrine (PE) (T+PP+PE) was considered the standard therapy, to which tropicamide alone (T alone) and tropicamide + proparacaine (T+PP) were compared against. Main outcome measures were postdilation pupil size and proportion of pupils able to achieve adequate clinical pupil dilation of >7 mm. Comparisons were made using Wilcoxon signed-ranked tests and McNemar's test. RESULTS: Mean postdilation pupil size was 7.94 ± 0.78 mm, 7.64 ± 0.78 mm, and 7.48 ± 0.77 mm for T+PP+PE, T+PP, and T alone, respectively. T+PP+PE was statistically superior to T+PP (p = 0.004) and T alone (p < 0.001) with respect to postdilation pupil size. The proportion of pupils able to achieve adequate pupil dilation of >7 mm was 90%, 80%, and 70% for T+PP+PE, T+PP, and T alone, respectively. No statistical difference was observed in each regimen's ability to achieve adequate pupil dilation of >7 mm (T+PP+PE and T+PP: p = 0.47; T+PP+PE and T alone: p = 0.13). CONCLUSION: The addition of phenylephrine eye drops to tropicamide produced larger pupil dilation, but the magnitude of benefit was marginal and clinically insignificant in this young, healthy cohort. A single-dilating-agent regimen using tropicamide could be considered in routine clinical practice.

Bremsstrahlung Dose Yield for High-Intensity Short-Pulse Laser-Solid Experiments.

A bremsstrahlung source term has been developed by the Radiation Protection (RP) group at SLAC National Accelerator Laboratory for high-intensity short-pulse laser-solid experiments between 1017 and 1022 W cm-2. This source term couples the particle-in-cell plasma code EPOCH and the radiation transport code FLUKA to estimate the bremsstrahlung dose yield from laser-solid interactions. EPOCH characterizes the energy distribution, angular distribution, and laser-to-electron conversion efficiency of the hot electrons from laser-solid interactions, and FLUKA utilizes this hot electron source term to calculate a bremsstrahlung dose yield (mSv per J of laser energy on target). The goal of this paper is to provide RP guidelines and hazard analysis for high-intensity laser facilities. A comparison of the calculated bremsstrahlung dose yields to radiation measurement data is also made.

Long-chain omega-3 fatty acids and blood pressure.

BACKGROUND: High dose fish oil supplementation reduces blood pressure (BP) in hypertensive patients. The current study examines how modest variations in omega-3 fatty acid intake may affect BP in a healthy community sample. METHODS: Study participants included 265 Pittsburgh-area adults 30-54 years of age (11% black, 51% female) not taking omega-3 fatty acid supplements or antihypertensive medications. Standardized assessments of clinic and 24-h ambulatory BP, and pulse rate were obtained. Docosahexanenoic acid (DHA) and eicosapentaenoic acid (EPA) in fasting serum phospholipids were measured by capillary gas chromatography. Regression analyses controlled for age, gender, race, body mass index (BMI), self-reported sodium intake, and physical activity. RESULTS: Participants included 181(68%) normotensives, 66 (25%) prehypertensives, and 18 (7%) persons with untreated hypertension. DHA was inversely associated with clinic diastolic (ß = -0.121, P = 0.03), awake ambulatory diastolic BP (ß = -0.164, P = 0.004), and 24-h diastolic BP (ß = -0.135, P = 0.02). A two standard deviation greater DHA was associated with 2.1 mm Hg lower clinic and 2.3 mm Hg lower awake ambulatory diastolic BP. In addition, DHA was inversely associated with pulse rate measured at rest in the clinic. EPA was related to clinic pulse rate but not clinic or ambulatory BP. CONCLUSION: In this sample of American adults not on antihypertensive medications, a modest, inverse association was found between DHA exposure and both clinic and ambulatory diastolic BP. Therefore, increasing DHA consumption through diet modification rather than large dose supplementation represents a candidate strategy for future studies of hypertension prevention.

Radiation safety system.

The goal of this work is to provide an overview of a Radiation safety system (RSS) designed for protection from prompt radiation hazard at accelerator facilities. RSS design parameters, functional requirements and constraints are derived from hazard analysis and risk assessment undertaken in the design phase of the facility. The two main subsystems of a RSS are access control system (ACS) and radiation control system (RCS). In this text, a common approach to risk assessment, typical components of ACS and RCS, desirable features and general design principles applied to RSS are described.