Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis.

OBJECTIVES: Utility of CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring in risk stratification prior to non-cardiac surgery is unclear. Although current guidelines recommend stress testing in intermediate-high risk individuals, over one-third of perioperative major adverse cardiovascular events (MACE) occur in patients with a negative study. This systematic review and meta-analysis evaluates the value of CTA and CAC score in preoperative risk prognostication prior to non-cardiac surgery. METHODS: MEDLINE, PubMed and EMBASE databases were searched for articles published up to June 2018. Summary ORs for degree of coronary artery disease (CAD) and perioperative MACE were pooled using a random-effects model. RESULTS: Eleven studies were included. Two hundred and fifty-two (7.2%) MACE occurred in 3480 patients. Risk of perioperative MACE rose with the severity and extent of CAD on CTA (no CAD 2.0%; non-obstructive 4.1%; obstructive single-vessel 7.1%; obstructive multivessel 23.1%, p<0.001). Multivessel disease (MVD) demonstrated the greatest risk (OR 8.9, 95% CI 5.1 to 15.3, p<0.001). Increasing CAC score was associated with higher perioperative MACE (CAC score: ≥100 OR 5.1, ≥1000 OR 10.4, both p<0.01). In a cohort deemed high risk by established clinical indices, absence of MVD on CTA demonstrated a negative predictive value of 96% (95% CI 92.8 to 98.4) for predicting freedom from MACE. CONCLUSIONS: Severity and extent of CAD on CTA conferred incremental risk for perioperative MACE in patients undergoing non-cardiac surgery. The 'rule-out' capability of CTA is comparable to other non-invasive imaging modalities and offers a viable alternative for risk stratification of patients undergoing non-cardiac surgery. TRIAL REGISTRATION NUMBER: CRD42018100883.

First contact diagnosis and management of contact lens-related complications.

To describe the spectrum of contact lens-related problems in cases presenting to a tertiary referral eye hospital. A retrospective case record analysis of 111 eyes of 97 consecutive patients was undertaken over a period of five months at the Royal Victorian Eye and Ear Hospital, Melbourne, Australia. Contact lens-related complications (CLRC) were classified into microbial keratitis, sterile corneal infiltrates, corneal epitheliopathy and contact lens-related red eye (CLARE). Main parameters examined were nature of the first contact, clinical diagnosis, and management pattern. Forty-two percent of the initial presentations were to health care practitioners (HCPs) other than ophthalmologists. Mean duration from the onset of symptoms to presentation was 6.3 ± 10.9 days. Forty-nine percent (n = 54) of patients had an associated risk factor, most commonly overnight use of contact lenses (n = 14, 13 %). Most common diagnosis at presentation was corneal epitheliopathy (68 %) followed by sterile infiltrates (10 %), CLARE (8 %) and microbial keratitis (6 %). No significant differences were found in the pattern of treatment modalities administered by ophthalmologists and other HCPs. HCPs other than ophthalmologists are the first contact for contact lens-related problems in a significant proportion of patients. These HCPs manage the majority of CLRC by direct treatment or immediate referral.

Endogenous endophthalmitis associated with intravenous drug abuse: seven-year experience at a tertiary referral center.

PURPOSE: Intravenous drug use (IVDU) is a known risk factor for endogenous endophthalmitis. Endogenous fungal endophthalmitis (EFE) is emerging as a common problem among this community. We describe the management and visual outcomes of acute IVDU-associated EFE. METHODS: A prospective consecutive case series of 19 patients presenting with presumed acute IVDU-associated EFE from 2001 to 2007 to the Royal Victorian Eye and Ear Hospital was included. All data were collected in a standardized manner. Outcome measures included visual acuity, microbial profiles, and vitrectomy rate. RESULTS: Nineteen cases of IVDU-associated EFE were identified. Eight of these (42%) were men, and the mean age was 32.7 years (SD ± 8.0 years). Presenting visual acuity ranged from 6/6 to perception of light, with 58% having a visual acuity of 6/48 or less at presentation. Thirteen (68.4%) were culture positive with all cultures identifying Candida species, and 52.7% underwent vitrectomy. Fifty percent of subjects overall achieved a final visual acuity of 6/18 or better. Men demonstrated improved visual acuity when compared with women (P = 0.04). Age had no effect on final acuity. CONCLUSION: Intravenous drug use is a significant risk factor for developing EFE. Good visual outcomes can be achieved with early treatment, often with intravitreal therapy alone.

A cohort study of the effects of serum osteoprotegerin and osteoprotegerin gene polymorphisms on cardiovascular mortality in elderly women.

OBJECTIVE: To investigate the role of serum osteoprotegerin (OPG) and OPG gene polymorphisms in relation to cardiovascular (CV) and all-cause mortality in elderly women. BACKGROUND: The OPG/RANK/RANKL plays a vital role in bone cell biology. It has also been detected in myocardial tissue and atherosclerotic plaques. In some population studies, OPG and OPG gene polymorphisms have been associated with CV disease risk. DESIGN, MEASUREMENTS AND RESULTS: In an 8.5-year cohort population study of 1333 postmenopausal women mean age 75.2 ± 2.7 years, serum OPG concentrations above the median were associated with an increased risk of all-cause [odds ratio (OR) 1.39 (1.04-1.85)], and in particular CV mortality [OR 1.83 (1.10-3.05)], before and after adjusting for age, BMI, treated hypertension, diabetes, hypercholesterolemia, previous HRT use, calcium supplementation and smoking. Genotyping the OPG gene did not provide further information on the association between OPG and CV risk or mortality events. CONCLUSIONS: Raised osteoprotegerin appears to be an independent risk factor for total and CV death and thus has potential as a useful biomarker of risk as well as a potential target for therapeutic intervention.

Prevalence and characteristics of choroidal nevi in an Asian vs white population.

OBJECTIVE: To describe the prevalence and characteristics of choroidal nevi in an Asian population and compare this with findings from a white population. METHODS: The Singapore Malay Eye Study (SiMES) examined a population-based, cross-sectional, age-stratified, random sample of 3280 Malay persons (78.7% participation rate) aged 40 to 80 years living in Singapore. Comprehensive examination of participants included bilateral retinal photography. Choroidal nevi were graded from photographs using the Blue Mountains Eye Study (BMES) protocol. RESULTS: The person-specific prevalence of choroidal nevi was 1.4%, with 50 nevi found in 45 participants. This is lower than the 6.5% prevalence seen in white persons in the BMES. However, characteristics of nevi in Malay persons in the SiMES were similar to those of white persons in the BMES by size (SiMES, 1.27 mm; BMES, 1.25 mm; P = .35), shape (P = .58), color (P = .39), location within posterior pole or periphery (P = .30), and nevus margin proximity to the optic disc (P = .29). Features previously identified as indicating growth or malignant potential (including diameter >6 mm, posterior margin touching optic disc, orange pigment, pigment clumping, and retinal edema) were not found in this sample. CONCLUSION: Choroidal nevi were detected in 1.4% of Malay persons. There were no significant racial or ethnic differences in nevi characteristics between Malay and white persons.

Relationship of axial length and retinal vascular caliber in children.

PURPOSE: Previous studies in older adults suggest that longer axial length is associated with narrower arteriolar caliber. In this study, we re-examined this relationship in a cohort of children, while controlling for the effects of ocular magnification. DESIGN: Cross-sectional study of 767 children aged 7 to 9 years. METHODS: Retinal vascular calibers were measured from retinal photographs using a computer-based program. Ocular magnification was corrected using the Bengtsson formula. Standardized examination of refraction and ultrasound ocular biometry was performed for all children. RESULTS: In models that adjusted for age, gender, ethnicity, body mass index, blood pressure, and birth weight, longer axial length was associated strongly with narrower retinal arteriolar caliber (3.18-microm decrease per standard deviation increase in axial length; P < .001) and venular caliber (4.62-microm decrease standard deviation increase in axial length; P < .001) before correction for ocular magnification. However, after correction, these associations no longer were significant (0.44 microm; P = .31, change for arteriolar caliber; and 0.70 microm; P = .25, for venular caliber). CONCLUSIONS: Our study in children found no association between axial length and retinal vascular caliber after correcting for ocular magnification, suggesting that the previously reported association was likely related to differences in ocular magnification.

Three-year incidence and cumulative prevalence of retinopathy: the atherosclerosis risk in communities study.

PURPOSE: To describe the three-year incidence and cumulative prevalence of retinopathy and its risk factors. DESIGN: Population-based, prospective cohort study in four US communities. METHODS: In the Atherosclerosis Risk in Communities (ARIC) Study, 981 participants had retinal photography of one randomly selected eye at the third examination (1993 to 1995) and three years later at the fourth examination (1996). Photographs were graded on both occasions for retinopathy signs (for example, microaneurysm, retinal hemorrhage, and/or cotton-wool spots). Incidence was defined as participants without retinopathy at the third examination who developed retinopathy at the fourth examination, and cumulative prevalence was defined to include incident retinopathy as well as participants who had retinopathy at both the third and fourth examinations. RESULTS: The three-year incidence and cumulative prevalence of any retinopathy in the whole cohort was 3.8% and 7.7%, respectively. In multivariable analysis, incident retinopathy was related to higher mean arterial blood pressure (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0 to 2.3, per standard deviation increase in risk factor levels), fasting serum glucose (OR 1.6, 95% CI 1.3 to 2.1), serum total cholesterol (OR 1.4, 95% CI 1.0, 2.0), and plasma fibrinogen (OR 1.4, 95% CI 1.1 to 1.9). Among persons without diabetes, the three-year incidence and cumulative prevalence of nondiabetic retinopathy was 2.9% and 4.3%, respectively. Incident nondiabetic retinopathy was related to higher mean arterial blood pressure (OR 1.4, 95% CI 0.9 to 2.3) and fasting serum glucose (OR 1.5, 95% CI 1.0 to 2.3). Among persons with diabetes, the three-year incidence and cumulative prevalence of diabetic retinopathy was 10.1% and 27.2%, respectively. CONCLUSIONS: Retinopathy signs occur frequently in middle-aged people, even in those without diabetes. Hypertension and hyperglycemia are risk factors for incident retinopathy.