Peripheral Neurectomy With Customized Nerve Reconstruction for Periorbital Neuropathic Pain: Initial Experience and Clinical Outcomes.

PURPOSE: To describe a novel, minimally invasive surgical technique to treat severe, intractable periorbital neuropathic pain. METHODS: A retrospective analysis of patients with severe, treatment-refractory periorbital pain who underwent transection of affected sensory trigeminal branches with nerve repair was performed. Collected data included etiology and duration of neuropathic pain, comorbidities, prior treatment history, surgical technique including site of transected sensory nerves and type of nerve repair, preoperative and postoperative pain scores as well as follow-up duration. Differences between preoperative and postoperative values were analyzed by the Wilcoxon signed-rank test. RESULTS: A total of 5 patients with severe periorbital neuropathic pain underwent transection of affected supraorbital, supratrochlear, infratrochlear, infraorbital, zygomaticotemporal, and zygomaticofacial nerves with customized nerve reconstruction. All 5 had improvement of periorbital pain after surgery, with 3 (60%) noting complete resolution of pain and 2 (40%) experiencing partial pain relief over a median follow-up period of 9 months (interquartile range [IQR], 6-19 months). Of the 3 patients who had complete resolution of pain, all reported continued pain relief. Median McGill pain scores significantly decreased from 8.4 (IQR, 8.2-10.0) preoperatively to 0.0 (IQR, 0.0-4.8; p < 0.001) postoperatively. All patients reported satisfaction with the surgical procedure and stated that they would undergo the procedure again if given the option. One patient with history of postherpetic neuralgia (PHN) had reactivation of herpes zoster at postoperative month 3, which was self-limited, without worsening of her neuropathic pain. Another patient with PHN required a staged procedure to achieve complete pain relief. CONCLUSION: Peripheral neurectomy with customized reconstruction of involved sensory nerves can successfully reduce and even eradicate periorbital neuropathic pain that was previously recalcitrant to combination pharmacotherapy and prior neurolysis procedures.

MRI of posterior eye shape and its associations with myopia and ethnicity.

PURPOSE: To evaluate posterior eye shape variations across a wide refractive error range using brain MRI in a multiethnic cohort. METHODS: Adult subjects in the multiethnic Singapore Epidemiology of Eye Disease study were included. Spherical equivalent (SE) was measured using subjective refraction, and axial length (AL) was measured using optical biometry. MRI was performed using a 3-Tesla whole body scanner with a 32-channel head coil. The radii and asphericity based on fitting of the posterior two-thirds of the eye (240°) were calculated. The refractive error status was categorised as myopic (SE<-0.5 D) or non-myopic (SE≥-0.5 D). RESULTS: A total of 450 adult participants (mean age 64.2±6.5 years old) were included. Less oblate asphericity was associated with more myopic SE, longer AL and with a refractive error categorisation of myopia (p<0.001 for all). Asphericity values were less oblate in myopic compared with non-myopic eyes (p<0.001). Multivariate analysis showed that Chinese subjects had less oblate eyes than Malay and Indian subjects, especially in non-myopic eyes. CONCLUSIONS: A less oblate posterior eye shape was associated with myopic eyes. Chinese eyes have less oblate shapes than Malay and Indian eyes, especially in non-myopic eyes.

Minimally Invasive Corneal Neurotization With Acellular Nerve Allograft: Surgical Technique and Clinical Outcomes.

PURPOSE: To describe a minimally invasive surgical technique and its clinical outcomes with the use of acellular nerve allograft to re-establish corneal sensibility in patients with neurotrophic keratopathy. METHODS: Acellular nerve allograft was coapted to an intact supraorbital, supratrochlear, or infraorbital nerve and transferred to the affected eye. Donor nerve pedicles were isolated through a transpalpebral or transconjunctival approach. Retrospective evaluation of preoperative and postoperative corneal sensibility, ocular surface, and best-corrected visual acuity was performed in all patients. Mean follow-up period was 6 months (range: 3-10 months). RESULTS: Corneal neurotization with acellular nerve allograft was successfully performed in 7 patients with restoration of corneal sensibility and corneal epithelial integrity. In vivo confocal microscopy demonstrated increased nerve density in corneal stroma at 4 months after surgery. CONCLUSIONS: The use of acellular nerve allograft allows for a minimally invasive approach to successful corneal neurotization.

Retinal imaging in human autopsy eyes using a custom optical coherence tomography periscope.

Age-related macular degeneration (AMD) is a major cause of vision loss in the elderly. To better study the pathobiology of AMD, postmortem eyes offer an excellent opportunity to correlate optical coherence tomography (OCT) imaging characteristics with histopathology. However, postmortem eyes from autopsy present challenges to standard OCT imaging including opaque anterior segment structures and standard of care autopsy processing resulting in oblique views to the macula. To overcome these challenges, we report a custom periscope attached by a standard mount to an OCT sample arm and demonstrate high quality macular OCT acquisitions in autopsy-processed eyes.

Accessibility and Barriers to Oncology Appointments at 40 National Cancer Institute-Designated Comprehensive Cancer Centers: Results of a Mystery Shopper Project.

PURPOSE: Patients turn to National Cancer Institute (NCI) -designated comprehensive cancer centers because of perceived better quality and more timely access to care. However, recent studies have found that patients at various institutions may struggle to gain access to an appointment or obtain consistent information from attendants. Our study employs a mystery shopper format to identify and quantify barriers faced by patients seeking to make a first consultation appointment across a homogenous sample of 40 NCI-designated comprehensive cancer centers. METHODS: Five mystery shoppers used a standardized call script to inquire about first available appointment times and service offerings. RESULTS: When inquiring about a date for a first available appointment, 29% of callers were unable to secure an estimated date without registering into the center's database, 51% were able to secure an estimated date, and 20% were provided with an actual date. Of estimated or actual dates for a first available appointment, 74% were greater than 1 week away. There was no statistically significant variation between appointment availability across insurance type or US region. CONCLUSION: Our study highlights the difficulty of accessing information about appointment availability. Although not statistically significant, inquiries regarding first available appointments for Medicaid patients resulted in longer estimated or actual wait times than those for patients with private insurance, and Medicaid shoppers noted qualitative differences. Although our study was limited by small sample size and imperfect analytic methods, our results suggest the need for more efficient and accessible care for patients at our nation's top cancer centers.

Cefepime and Ceftazidime Safety in Hospitalized Infants.

BACKGROUND: Cefepime and ceftazidime are cephalosporins used for the treatment of serious Gram-negative infections. These cephalosporins are used off-label in the setting of minimal safety data for young infants. METHODS: We identified all infants discharged from 348 neonatal intensive care units managed by the Pediatrix Medical Group between 1997 and 2012 who were exposed to either cefepime or ceftazidime in the first 120 days of life. We reported clinical and laboratory adverse events occurring in infants exposed to cefepime or ceftazidime and used multivariable logistic regression to compare the odds of seizures and death between the 2 groups. RESULTS: A total of 1761 infants received 13,293 days of ceftazidime, and 594 infants received 4628 days of cefepime. Laboratory adverse events occurred more frequently on days of therapy with ceftazidime than with cefepime (373 vs. 341 per 1000 infant days, P < 0.001). Seizure was the most commonly observed clinical adverse event, occurring in 3% of ceftazidime-treated infants and 4% of cefepime-treated infants (P = 0.52). Mortality was similar between the ceftazidime and cefepime groups (5% vs. 3%, P = 0.07). There was no difference in the adjusted odds of seizure [odds ratio (OR) = 0.96 (95% confidence interval: 0.89-1.03)] or the combined outcome of mortality or seizures [OR = 1.00 (0.96-1.04)] in infants exposed to ceftazidime versus those exposed to cefepime. CONCLUSIONS: In this cohort of infants, cefepime was associated with fewer laboratory adverse events than ceftazidime, although this may have been due to a significant difference in clinical exposures and severity of illness between the 2 groups. There was no difference in seizure risk or mortality between the 2 drugs.