Standard anterior peritomy versus a small posterior incision for the implantation of the PRESERFLO microshunt.

PURPOSE: To compare two approaches for the implantation of the PRESERFLO microshunt: an anterior approach (A) with a 6-8-mm peritomy and a posterior approach (P) with a 3-mm incision. METHODS: We retrospectively analyzed 126 patients who received a PRESERFLO microshunt. We compared intraocular pressure (IOP), surgical time, medication count, and postoperative complications over nine months. RESULTS: The baseline IOP was similar in A (21.8 ± 8.5 mm Hg) and P (23.9 ± 8.1 mm Hg) (p = 0.08). Surgical duration was significantly shorter in P (10 ± 0.4 min) than in A (26 ± 0.8 min) (p < 0.001). Postoperative IOP levels were comparable in A (10.8 ± 5.9 mm Hg) and P (10.6 ± 4.5 mm Hg) at 30 days (p = 0.62) and throughout the study (all intra-group p-values > 0.08). The preoperative medication count was 3.2 ± 1.3 drops in A and 3.3 ± 1.0 drops in P (p = 0.4). Postoperative values were 0.2 ± 0.6 in A and 0.3 ± 0.7 in P at nine months. There were no significant differences in complications and surgical revisions between groups (p-values > 0.05). CONCLUSION: Both techniques achieved satisfactory IOP and medication count reductions and had similar safety profiles, but the posterior incision technique was 2.6 times faster than the anterior incision technique.

Trabeculopuncture as a predictive test of distal outflow resistance in canal-based surgery.

We investigated whether trabeculopuncture (TP) could detect distal outflow resistance to predict the outcome of canal-based glaucoma surgery such as ab interno trabeculectomy (AIT). These procedures have a high utilization in open angle glaucoma, but fail in eyes with an unidentified distal outflow resistance. We assigned 81 porcine eyes to two groups: trial (n = 42) and control (n = 39). At 24 h, four YAG-laser trabeculopunctures were placed nasally, followed by a 180° AIT at the same site at 48 h. The proportion of TP responders between both AIT groups was compared. Histology and outflow canalograms were determined. Both post-TP and post-AIT IOPs were lower than baseline IOP (p = 0.015 and p < 0.01, respectively). The success rates of TP and AIT were 69% and 85.7%, respectively. Sensitivity and specificity values of TP as predictive test for AIT success were 77.7% and 83.3%, respectively. The positive and negative predictive values were 96.6% and 38.5%, respectively. We conclude that a 10% reduction in IOP after TP can be used as a predictor for the success (> 20% IOP decrease) of 180° AIT in porcine eyes.

Outcomes of ab interno trabeculectomy with the trabectome after failed trabeculectomy.

AIM: To evaluate outcomes of ab interno trabeculectomy (AIT) with the trabectome following failed trabeculectomy. METHODS: Prospective study of AITs and phaco-AITs after a failed trabeculectomy. The indication for AIT was intraocular pressure (IOP) above target on maximally tolerated therapy, and for phaco-AIT a visually significant cataract and need to lower IOP or glaucoma medications. Outcomes included IOP, medications, complications, secondary procedures and success, defined as IOP of less than 21 mm Hg and a greater than 20% reduction from baseline without further surgery. Exclusion criteria were trabeculectomy less than 3 months prior to AIT or follow-up under 1 year. RESULTS: Seventy-three eyes of 73 patients with 1 year follow-up were identified. At 1 year, mean IOP in AIT significantly decreased by 28% from 23.7±5.5 mm Hg, and medications from 2.8±1.2 to 2±1.3 (n=58). In phaco-AIT, the mean IOP decreased 19% from 20±5.9 mm Hg and medications from 2.5±1.5 to 1.6±1.4 (n=15). Transient hypotony occurred in 7%, and further surgery was necessary in 18%. For AIT and phaco-AIT, the 1-year cumulative probability of success was 81% and 87%, respectively. CONCLUSIONS: Both AIT and phaco-AIT showed a reduction in IOP and medication use after 1 year, suggesting that AIT with or without cataract surgery is a safe and effective option following failed trabeculectomy.

Outcomes of ab interno trabeculectomy with the trabectome by degree of angle opening.

AIM: To analyse ab interno trabeculectomy (AIT) with the trabectome and combined phacoemulsification with AIT (phaco-AIT) by Shaffer angle grade (SG). METHODS: Prospective study of AIT and phaco-AIT with narrow angles of SG≤2 versus open angles ≥3. Outcomes included intraocular pressure (IOP), medications, complications, secondary surgery and success (IOP <21 mm Hg and >20% reduction without further surgery). Exclusion criteria were missing preoperative data and <1 year follow-up. RESULTS: Of 671 included cases, at 1 year AIT SG≤2 (n=43) had an IOP reduction of 42% from 27.3±7.4 to 15.7±3.0 mm Hg (p<0.01) versus AIT SG≥3 (n=271) with an IOP reduction of 37% from 26.1±7.8 to 16.4±3.9 mm Hg (p<0.01). In phaco-AIT with SG≤2 (n=48), IOP was reduced 24% from 20.7±7.0 to 15.7±3.6 mm Hg (p<0.01) versus phaco-AIT with SG≥3 (n=309) with an IOP reduction of 25% from 22.6±6.4 to 17.0±3.4 mm Hg (p<0.01). There was no difference between SG≤2 and SG≥3 in reduction of IOP or medications, complications, secondary surgery and success rates (p>0.05). CONCLUSIONS: SG≤2 is not associated with worse outcomes in AIT or phaco-AIT.

Genomic response of hypoxic Müller cells involves the very low density lipoprotein receptor as part of an angiogenic network.

Müller cells have recently been found to produce select angiogenic substances. In choosing a more comprehensive approach, we wanted to study the genomic response of Müller cells to hypoxia to identify novel angiogenic genes. An established Müller cell line (rMC-1) was exposed to standard or hypoxic conditions. We analyzed gene expression with three independent microarrays and determined differential expression levels compared to normoxia. Selected genes were confirmed by real-time PCR (RTPCR). Subcellular localization of proteins was examined by immunocytochemistry. A network-based pathway analysis was performed to investigate how those genes may contribute to angiogenesis. We found 19,004 of 28,000 known rat genes expressed in Müller cells. 211 genes were upregulated by hypoxia 1.5 to 14.9-fold (p<0.001, FDR

Genetic modification of human trabecular meshwork with lentiviral vectors.

Glaucoma, a group of optic neuropathies, is the leading cause of irreversible blindness. Neuronal apoptosis in glaucoma is primarily associated with high intraocular pressure caused by chronically impaired outflow of aqueous humor through the trabecular meshwork, a reticulum of mitotically inactive endothelial-like cells located in the angle of the anterior chamber. Anatomic, genetic, and expression profiling data suggest the possibility of using gene transfer to treat glaucomatous intraocular pressure dysregulation, but this approach will require stable genetic modification of the differentiated aqueous outflow tract. We injected transducing unit-normalized preparations of either of two lentiviral vectors or an oncoretroviral vector as a single bolus into the aqueous circulation of cultured human donor eyes, under perfusion conditions that mimicked natural anterior chamber flow and maintained viability ex vivo. Reporter gene expression was assessed in trabecular meshwork from 3 to 16 days after infusion of 1.0 x 10(8) transducing units of each vector. The oncoretroviral vector failed to transduce the trabecular meshwork. In contrast, feline immunodeficiency virus and human immunodeficiency virus vectors produced efficient, localized transduction of the trabecular meshwork in situ. The results demonstrate that lentiviral vectors permit efficient genetic modification of the human trabecular meshwork when delivered via the afferent aqueous circulation, a clinically accessible route. In addition, controlled comparisons in this study establish that feline and human immunodeficiency virus vectors are equivalently efficacious in delivering genes to this terminally differentiated human tissue.

Experience with oseltamivir in the control of a nursing home influenza B outbreak.

Oseltamivir prophylaxis was very effective in protecting nursing home residents from ILI and in halting this outbreak of influenza B. A portion of the total ILI cases may have been due to influenza A, as this strain was isolated in one resident. The 10% attack rate in this facility, controlled with oseltamivir, compares favourably with another influenza B outbreak in a similar facility in the same region, over the same time frame (ILI onset 27 December to 17 January). Oseltamivir prophylaxis was not used to manage this second outbreak of laboratory-confirmed influenza B. Of the 236 residents, 45 developed ILI for an overall attack rate of 19%, nearly double the rate in the oseltamivir-controlled setting (10%). While oseltamivir was effective in controlling influenza B in this outbreak, further experience and evaluation is required before it can be routinely recommended for prophylaxis of influenza in nursing home outbreaks. Although earlier attempts by others using oseltamivir in the control of influenza A outbreaks have also met with success, it is not yet licensed for this purpose. Compared to amantadine, oseltamivir has a relatively high cost for the control of influenza A outbreaks and this may continue to limit its wider acceptance. The cost-effectiveness of oseltamivir in the control of influenza B outbreaks needs to be specifically addressed given the typically milder nature of influenza B strains. However, such a distinction is not clinically reliable and elderly residents of long-term care facilities remain vulnerable to serious complications associated with influenza infection in general. An alternate agent for influenza chemoprophylaxis that is effective against both influenza A and B, is easily administered and has few side effects, could greatly enhance current prevention and control measures and warrants serious assessment. The spread of this outbreak from the geographically separate ward to other areas of the facility in which residents had not received prophylaxis, underscores the likely role of staff as a vehicle for transmission during facility outbreaks. While accurate staff ILI rates could not be determined, their immunization rates were low, and many staff were ill during the outbreak. Isolation of residents with ILI and prophylaxis of non-ill residents on the initial outbreak wards was insufficient to prevent the spread of the outbreak, although it was subsequently halted once prophylaxis was extended to all residents. In view of the uncertainty over this medication's widespread use, in the absence of licensure or previous studies demonstrating its effectiveness in the prophylaxis and control of influenza B outbreaks, initiation of oseltamivir prophylaxis was staggered by ward. In a declared influenza A outbreak, the protocol in a long term care facility is to initiate amantadine prophylaxis on all residents, rather than ward-by-ward. While anti-viral prophylaxis may be an effective secondary control measure in the management of influenza outbreaks, optimal primary prevention would be more effective. This would require increased vaccine coverage of residents and particularly of staff, who play an important role in the importation and transmission of influenza within these facilities.

[Experiences with cycloplegic drops in German-speaking centers of pediatric ophthalmology and stabology--results of a 1999 survey]. / Zykloplegie-Tropferfahrungen in deutschsprachigen Zentren für Kinderophthalmologie und Strabologie--Umfrageergebnisse 1999.

BACKGROUND: Because of its advantages, topical cyclopentolate is often preferred over the gold standard, atropine. The purpose of the study was to obtain an overview over current cycloplegia protocols and to estimate the likelihood of severe complications due to the use of cycloplegics. METHODS: A questionnaire was sent to 107 German-speaking centres with a supposed high cycloplegia frequency. RESULTS: 57 centres answered, whereby 1,112 cumulated years of experience with cycloplegia were available for analysis. The frequency of cycloplegias varied between 2 and 180/week/centre, median 25/week/centre. A cumulated amount of 1.7 million cycloplegias was computed. The average extrapolated experience with cycloplegia was 49,000 cycloplegias/30 years. Severe complications which would cause a medical follow up of several hours or which led to a follow up in a ward were named 47 times and 2 times, respectively. CONCLUSIONS: During 30 years of a cycloplegia career with an average of 34 cycloplegias/week, one may expect 2-10 severe complications. In current practice, the patient risk of severe complications is very small. Health care professionals and parents should be informed about the frequent occurrence of light side effects in order to reach a good compliance with cycloplegia.

The use of cycloplegic agents. Results of a 1999 survey of German-speaking centers for pediatric ophthalmology and strabology.

INTRODUCTION: Because of its advantages, topical cyclopentolate is often preferred over the gold standard, atropine. The purpose of this study was to obtain an overview over current cycloplegia protocols and to estimate the likelihood of severe complications due to the use of cycloplegics. METHODS: A questionnaire was sent to 107 German-speaking centers with a supposed high frequency of cycloplegias. RESULTS: 57 centers answered, whereby 1,112 cumulated years of experience with cycloplegia were available for analysis. The frequency of cycloplegias varied between 2 and 180/week/center, median 25/week/center. A cumulated total of 1.7 million cycloplegias was computed. The extrapolated average experience with cycloplegia was 49,000 cycloplegias/30 years. Complications which would warrant a medical follow-up of several hours (severe complications) or which led to a follow-up in a ward (very severe complications) were named 47 times and 2 times, respectively. DISCUSSION: During 30 years of a cycloplegia career with an average of 34 cycloplegias/week, one may expect 2-10 severe or very severe complications. In current practice, the patient risk of severe complications is very small. Health care professionals and parents should be informed about the frequent occurrence of harmless side effects in order to achieve a good compliance with cycloplegia.

Development of the Abbott AxSYM Free PSA assay: performance characteristics and preliminary clinical evaluation.

The AxSYM Free PSA assay was demonstrated to have good analytical sensitivity and reproducibility. The F/T ratio determinations for 385 men tested during the Prostate Awareness Week who had biopsies due to an elevated total PSA value and/or a suspicious DRE demonstrated that the percentage of free PSA was lower in patients found to have prostate cancer than those that were biopsy negative for the overall group and for all patient categories examined. The optimal strategy for combining PSA values, F/T ratios, DRE and other clinical and diagnostic parameters to improve the early detection of prostate cancer requires additional clinical studies.

Adverse exposures and universal precautions practices among a group of highly exposed health professionals.

An anonymous national survey of a representative population of healthcare workers who were thought likely to have frequent and intensive exposures to blood and other body fluids (certified nurse-midwives [CNMs]), was conducted to assess the type and frequency of self-reported occupational exposures to blood and body fluids experienced, the extent to which barrier precautions and other infection control measures were used, whether or not reported use of barriers was associated with a lower perceived rate of exposures and factors that influenced the use of infection control procedures. Of those responding, 74% had soiled their hands with blood at least one time in the preceding six months, 51% had splashed blood or amniotic fluid in their faces and 24% reported one or more needlestick injuries during that same period. Our study also found evidence of an association between the practice of needle recapping and the occurrence of needlestick injury (p = .003). Despite a high level of training and knowledge, only 55% reported routinely practicing universal precautions (UPs). Several factors that potentially influenced the use of UPs were studied, including healthcare worker perceptions of risk of occupational bloodborne infection, knowledge of routes of transmission of bloodborne pathogens and rationale for not using appropriate barriers. Our data suggest that occupational exposures occur frequently and that healthcare workers' (HCWs') perceptions of risk for occupational infection play an important role in influencing use of UPs. This study emphasizes the importance of developing new strategies for UP training.

Use of precautions by nurse-midwives to prevent occupational infections with HIV and other blood-borne diseases.

A questionnaire was designed with these objectives: (1) to determine the frequency and type of adverse exposures experienced by certified nurse-midwives (CNMs); (2) to determine the extent to which CNMs used recommended precautions to prevent such incidents; and (3) to identify the sources used for obtaining information on AIDS. The questionnaire was mailed to all CNMs with the exception of associate and student members of the American College of Midwives. A response rate of 1,784/2,963 (60.2%) was obtained. These midwives reported frequent exposures to blood and body fluids. Sixty-five percent reported being soaked to the skin with blood or amniotic fluid; 50.7% had face-splashes with blood or amniotic fluid; and 24.0% experienced one or more needlestick(s). Only 55.1% reported using Universal Precautions (UP). Interference with the midwife-client relationship was identified most frequently as the reason for not using UP. Strategies need to be developed for midwives that will increase the use of UP and minimize the frequency of adverse exposures, while maintaining a caring midwife-client relationship.