Outcomes among patients undergoing transcatheter aortic valve replacement with very low baseline gradients.

Background: While there is evidence that patients with low-flow, low-gradient aortic stenosis (AS) benefit from transcatheter aortic valve replacement (TAVR), data are lacking regarding outcomes of patients with a very low gradient (VLG). Methods: In this retrospective, single-center study of patients with severe AS who underwent TAVR, three groups were defined using baseline mean aortic valve gradient: VLG (≤25 mmHg), low gradient (LG, 26-39 mmHg), and high gradient (HG, ≥40 mmHg). The primary outcome was the composite of Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 of <45, decrease in KCCQ-12 of ≥10 compared with baseline, or death at 1 year. Results: One-thousand six patients were included: 571 HG, 353 LG, and 82 VLG. The median age was 82.1 years [interquartile range (IQR) 76.3-86.9]; VLG patients had more baseline comorbidities compared with the other groups. The primary outcome was highest at 1 year in the VLG group (VLG, 46.7%; LG, 29.9%; HG, 23.1%; p = 0.002), with no difference between groups after adjustment for baseline characteristics. At baseline, <30% of VLG patients had an excellent or good (50-100) KCCQ-12, whereas more than 75% and 50% had an excellent or good KCCQ-12 at 30-day and 1-year follow-up, respectively. Conclusion: Although patients with VLG undergoing TAVR have a higher rate of poor outcomes at 1 year compared with patients with LG and HG severe AS, this difference is largely attributable to baseline comorbidities. Patients with severe AS undergoing TAVR have significant improvement in health status outcomes regardless of resting mean gradient.

PROLONGED OZURDEX-MACULAR CONTACT FOLLOWING VITRECTOMY FOR MACULAR HOLE.

PURPOSE: To evaluate the outcome of prolonged ozurdex-macular contact following vitrectomy for macular hole. METHODS AND PATIENTS: A 63-year-old woman with subtle vitreomacular traction and macula edema in the left eye underwent femto laser-assisted cataract surgery with lens implant and ozurdex injection. Postoperatively, patient developed macular hole for which she underwent vitrectomy. RESULTS: The steroid implant that remained in contact with the fovea for 16 weeks disappeared on its own without causing any retinal toxicity, and the best-corrected visual acuity improved to 6/9. CONCLUSION: Vitreomacular traction with edema may worsen after cataract surgery and ozurdex injection. Ophthalmologists should keep in mind this rare possible complication and make patients aware of the same.

Current state of transcatheter mitral valve implantation in bioprosthetic mitral valve and in mitral ring as a treatment approach for failed mitral prosthesis.

With heightened awareness of mitral valve disease and improvement in surgical techniques, the use of mitral valve bioprostheses has increased. There is a large aging population with prior surgical valvular interventions. Limited durability of the prosthesis due to valvular degeneration over time may necessitate the need for repair or replacement of the prior prosthesis in the future. This usually entails another surgical intervention in this population with elevated risk for a reoperation. There is an ongoing clinical need for newer, less invasive options that are feasible and carry a lower complication rate. The advent of transcatheter heart valve (THV) therapies has opened up a wide range of therapeutic options for treatment of a failed bioprosthesis. Their safety and feasibility are now well established. This article serves as a review of the currently available THVs for implantation in the mitral position, the pre-procedural assessment, the challenges associated with implantation, as well as outcomes associated with a mitral valve-in-valve (VIV) and a mitral valve-in-ring (VIR) procedure.

The Spontaneous Coronary Slow-Flow Phenomenon: Reversal by Intracoronary Nicardipine.

OBJECTIVE: An under-recognized cause of chest pain, the coronary slow-flow (CSF) phenomenon is characterized by delayed coronary opacification during diagnostic angiography in the absence of epicardial coronary artery disease (CAD). Given its angiographic resemblance to no-reflow during percutaneous coronary intervention, a condition associated with microvascular spasm responsive to calcium-channel blockers, we hypothesized that spontaneous CSF may similarly be reversed by intracoronary (IC) nicardipine. METHODS: The effect of IC nicardipine was evaluated in 30 patients. CSF was defined as spontaneously delayed flow (27) in 68/90 vessels (76%). IC nicardipine produced markedly accelerated coronary filling, which was corroborated by TFC analysis. TFC was 47 ± 17 before vs 15 ± 5 after nicardipine (P<.001). All vessels demonstrated TIMI 3 flow and TFC <28 after nicardipine treatment. CONCLUSIONS: IC nicardipine appears highly effective in reversing spontaneous CSF. These findings implicate microvascular spasm in the pathogenesis of CSF. Future studies of oral calcium-channel blockers in the long-term management of CSF are needed.

Comparison of Two Modified Sutureless Techniques of Scleral Fixation of Intraocular Lens.

BACKGROUND AND OBJECTIVE: To compare the visual outcome and complications of two different sutureless scleral-fixated intraocular lens (IOL) implantation techniques, that is, intrascleral IOL fixation technique and modified Yamane's technique of scleral fixation of IOL. PATIENTS AND METHODS: Patients who underwent scleral fixation of IOL (SFIOL) from June 2015 to February 2017 with more than 6 months of follow-up were examined retrospectively. Improvement in visual acuity (VA), intraocular pressure (IOP) measurements, endothelial cell count, central macular thickness (CMT), and intraoperative/postoperative complications were compared at 6 months follow-up. RESULTS: Seventy eyes were analyzed. The mean follow-up was 10.5 months ± 1.5 months. The final visual outcomes in both groups, modified intrascleral IOL fixation technique (Group A, n = 30) and modified Yamane's technique (Group B, n = 40), were comparable. The indications for surgery were aphakia (n = 15), subluxated/dislocated cataract (n = 31), and dislocated/subluxated IOL (n = 24). The majority of the eyes (92%) improved to VA 0.3 logMAR units or better. The uncorrected distance visual acuity (UDVA), endothelial cell density, and CMT at the 6-month follow-up were comparable in both groups. Postoperatively, transient IOP rise occurred in 18 eyes, retinal detachment in one eye, vitreous hemorrhage in one eye, cystoid macular edema in two eyes, and mild IOL decentration in two eyes. CONCLUSION: Both techniques have favorable visual outcomes; however, modified 27-gauge needle-assisted Yamane's technique is technically superior because of its transconjunctival approach and less surgical time, and its needle-assisted approach for haptic externalization prevents haptic damage during externalization. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e129-e134.].

Cataract surgery in diabetes mellitus: A systematic review.

India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results.

Precision pulse capsulotomy in phacoemulsification: Clinical experience in Indian eyes.

Purpose: To evaluate the surgical outcome of precision pulse capsulotomy (PPC) in phacoemulsification surgery. Methods: One hundred twenty-three eyes of 99 consecutive patients who underwent phacoemulsification with PPC through a 2.8 mm clear corneal incision were prospectively studied at a tertiary care centre. The size, shape of capsulotomy and intraoperative capsulotomy, and surgery-related complications were noted. Visual outcome, IOL stability, and signs of capsular opacification/contraction were evaluated at 3 and 6 months. Results: The mean age of patients was 49.5 ± 7.77 years. Complete, circular capsulotomy averaging 5.5 mm diameter was achieved in 117 of 123 eyes. In seven eyes, we experienced complications like capsulorhexis tear (n = 6) and inadvertent iris capture (n = 1). Probe malfunction occurred in six cases. Stable intracapsular intraocular lens (IOLs) fixation and centration was achieved in all eyes. None of the eyes had any significant posterior capsular opacification or capsular contraction at 3 and 6 months. In one eye anterior capsular opacification at the capsulotomy edge was noted at 6 months. Conclusion: PPC is a useful device for achieving a perfectly round capsulorrhexis. However, it has a learning curve and chances of skip areas in capsulorhexis, capsular tag, and its extension should be kept in mind. Special care should be taken in initial cases and while operating on eyes with poorly dilating pupil and mature cataracts.

Sutureless 27-gauge needle-assisted transconjunctival intrascleral intraocular lens fixation: Initial experience.

PURPOSE: The purpose of the study was to report our initial experience with the transconjunctival Intrascleral Intraocular Lens (SFIOL) fixation with modified Yamane's double-needle technique and flanged haptics. METHODS: This was a prospective interventional study that enrolled 31 consecutive patients undergoing SFIOL with the modified Yamane's technique. All patients underwent comprehensive evaluation including uncorrected and best-corrected vision, intraocular pressure, ultrasound biomicroscopy, endothelial cell density, and macular thickness using optical coherence tomography (OCT). We excluded patients with visually significant coexistent pathology such as corneal scars, macular pathology, and glaucoma. RESULTS: The mean age of subjects was 57 ± 16.9 years and 23 were men (74%). Surgery was performed for aphakia following complicated cataract surgery in 10 eyes (32%), with lensectomy for subluxated/dislocated cataract in 6 eyes (19%), and with IOL explantation for subluxated/dislocated IOL in 15 eyes (48%). There were no intraoperative complications. Uncorrected visual acuity improved from median of 1.48 logarithm of minimum angle of resolution (logMAR) units (interquartile range [IQR] = 1.3-2 logMAR) at baseline to 0.3 logMAR (IQR = 0.2-0.4 logMAR) at 6 weeks (P < 0.001) which was maintained at 6 months. There were no significant changes in endothelial cell density (P = 0.34) and OCT-based macular thickness (P = 0.31) at 6 months. Two eyes had slight IOL decentration. CONCLUSION: Our initial experience suggests that the Yamane's technique for SFIOL is a simple procedure with a short-learning curve and is independent of scleral flaps, tunnels, sutures, and fibrin glue. Using widely available 27-gauge needle instead of 30-gauge thin wall needle as originally described by Yamane makes it possible for the use of various three-piece IOLs available globally. Further studies are required for widespread acceptance of this technique.

Antibiotic prophylaxis practice patterns for cataract surgery in India - Results from an online survey.

PURPOSE: The aim of this study is to assess the current antibiotic prophylaxis practice patterns for cataract surgery in India. METHODS: This was a questionnaire-based E-survey carried out at a tertiary eye care center in India. An E-mail invitation to complete an online 20 point questionnaire survey was sent to all members of the All India Ophthalmological Society with valid E-mail addresses using a digital E-mail service. Duplicate entries were prevented. RESULTS: Out of 1228 total respondents (8.2%) who completed the survey 38% reported using routine intracameral (IC) antibiotic prophylaxis. Another 7% place antibiotics in the irrigating solution. Of those using IC antibiotic prophylaxis, 91% adopted this practice within the past 2 years; 92% are using moxifloxacin with 56% using a commercially available moxifloxacin formulation. Those predominantly performing phacoemulsification (43% vs. 25% performing mostly manual small incision cataract surgery, P < 0.001) and more than 500 cataract surgeries annually (45% vs. 33%, P < 0.001) reported greater use of IC moxifloxacin. Self-reported endophthalmitis rates were statistically significantly greater in those not using IC antibiotics (0.045% vs. 0.036, P = 0.04). Although a majority of respondents believe that IC antibiotics are an important option (54%) and that it is important to have a commercially available solution (68%), many believe that other antibiotic prophylaxis methods are sufficient (31%). CONCLUSION: IC antibiotic prophylaxis for cataract surgery has sharply increased in India. In contrast to the West, intraocular moxifloxacin, which is commercially available in India, is preferred by the vast majority of users.

A Rare Case of An Atypical Solitary Fibrous Tumour of Orbit.

Solitary fibrous tumours are of mesenchymal origin and comprise of uncommon spindle cell neoplasias. Most commonly the lesions arise from pleura but other rarer sites include lungs, peritoneum, pericardium, nasal cavities, thyroid, parotid gland and orbit. We report the case of a 41-year-old male patient who presented to us with a painless, progressive growth of a mass in the superior part of left orbit with proptosis and inferotemporal displacement of the left eye. Computed Tomography (CT) scan revealed homogeneous enhancing lesion in the superior compartment of left orbit in the extraconal region, extending intraconally and distorting the globe. Upon imaging, the differential diagnosis were lacrimal gland tumour, atypical cavernous haemangioma and nerve sheath tumour. Surgical treatment included complete excision of the mass with the intraoperative finding of mass extending upto the superior oblique tendon, a part of which was excised. Histopathological examination revealed CD34 positive, Bcl-2 and MIC-2 positive tumour with the diagnosis of a solitary fibrous tumour with atypical features but no malignant features. After a follow-up of 18 months, no recurrence was detected.

Herpes simplex virus encephalitis during treatment with etanercept.

Tumor necrosis factor alpha (TNF-α) inhibitors are widely used for the treatment of various inflammatory conditions. They are associated with an increased risk for infections. We report a case of herpes simplex virus type 1 (HSV-1) encephalitis in a patient receiving etanercept and review the literature on TNF-α and TNF-α inhibitors, and their importance in the pathophysiology of herpes simplex encephalitis.

The incidence and associated risk factors for sudden unexplained death in psychiatric in-patients in England and Wales.

Clinical characteristics and risk factors associated with sudden unexplained death (SUD) in the psychiatric population are unclear. Psychiatric in-patients (England, Wales) who met criteria for SUD were identified (1 March 1999-31 December 2005). Cases were matched with controls (in-patients alive on the day a SUD occurred). Data were collected via questionnaires. Some 283 cases of SUD were identified (41 annually), with a rate of 2.33/10,000 mental health admissions (in England). Electrocardiograms were not routine, cardiopulmonary resuscitation equipment was sometimes unavailable, attempts to resuscitate patients were carried out on one-half of all patients and post mortems/inquiries were not routine. Restraint and seclusion were uncommon. Risk factors included: benzodiazepines (odds ratio (OR): 1.83); ≥ 2 antipsychotics (OR: 2.35); promazine (OR: 4.02); diazepam (OR: 1.71); clozapine (OR: 2.10); cardiovascular disease (OR: 2.00); respiratory disease (OR: 1.98); diagnosis of dementia (OR: 2.08). Venlafaxine and a diagnosis of affective disorder were associated with reduced ORs (OR: 0.42; OR: 0.65). SUD is relatively rare, although it is more common in older patients and males. Prevention measures may include safer prescribing of antipsychotics and improved physical health care. The contribution of restraint or seclusion to SUD in individual cases is unclear. A uniform definition of SUD may help to identify contributing factors.

Mental illness, gender and homicide: a population-based descriptive study.

In England and Wales, a lifetime history of mental disorder is recorded in almost a third of homicides but mental illness as a defence in homicide cases has recently come under review. In this study, we aimed to compare the social, criminological and clinical characteristics of women and men convicted of homicide and secondly, to understand how pathways through the judicial system differ by gender of the perpetrator, characteristics of the offence and mental illness. A cross sectional study of 4572 convicted homicide perpetrators in England and Wales 1997-2004 was performed. Significantly more women who had committed homicide had a lifetime history of mental illness and were more likely to be mentally ill at the time of offence compared to men. Women more often received non-custodial sentences, whether or not they had mental illness. If the victim were a child or other relative, the courts were more lenient with women. Gender and the presence of mental illness both influence the characteristics of homicide and outcome of the legal process in the UK. Our findings suggest that all perpetrators of homicide should have a psychiatric assessment pre-trial. Psychiatrists need to rate risk objectively in a gender blind way when providing psychiatric reports to be used as evidence in court.

Cannabis and schizophrenia.

BACKGROUND: Many people with schizophrenia use cannabis and its effects on the illness are unclear. OBJECTIVES: To evaluate the effects of cannabis use on people with schizophrenia and schizophrenia-like illnesses. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group Trials Register (April 2007) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. SELECTION CRITERIA: We included all randomised trials involving cannabinoids and people with schizophrenia or schizophrenia-like illnesses. DATA COLLECTION AND ANALYSIS: We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated the numbers needed to treat/harm (NNT/NNH). For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model. MAIN RESULTS: We identified one randomised trial. No significant differences were found between the Cannabis and Psychosis Therapy (CAP) intervention group and the Psychoeducaton (PE) intervention for use of cannabis at three months assessment (n=47, RR 1.04 CI 0.6 to 1.7). BPRS-extended scale scores at three months assessment (n=47, WMD -3.60 CI -12.8 to 5.6) and nine months assessment (n=47, WMD 0.80 CI -7.5 to 9.1) were non-significant between CAP and PE. We found no significant improvement in social functioning in the CAP group compared with PE (at 3 months, n=47, WMD -0.80 CI -10 to 8.4) and (at 9 months, n=47, WMD -4.70 CI -14.5 to 5.1). AUTHORS' CONCLUSIONS: At present, there is insufficient evidence to support or refute the use of cannabis/cannabinoid compounds for people suffering with schizophrenia. This review highlights the need for well designed, conducted and reported clinical trials to address the potential effects of cannabis based compounds for people with schizophrenia.