Minimally invasive corneal neurotization for neurotrophic keratopathy: The potential effect of age, denervation chronicity and lesion location.

Purpose: Neurotrophic keratopathy (NK) is an uncommon but challenging clinical condition characterized by altered corneal nerves and sensation leading to corneal damage. Corneal neurotization, a surgical technique that aims to "re-innervate" the cornea, has gained increasing popularity in view of the potential to permanently improve or even restore the normal corneal sensation. In this study, we aimed to report the outcomes of two cases of NK that underwent indirect minimally invasive corneal neurotization (MICN) with a sural nerve autograft, and to provide plausible explanations for the observed clinical outcomes. Observations: This was an interventional case series of two patients who underwent MICN for severe unilateral NK. The MICN technique was adapted from the technique originally described by Elbaz et al., in 2014. Clinical severity of NK was graded according to Mackie's grading system. Corneal sensation was measured using the Cochet-Bonnet esthesiometer (0-60mm) and corneal nerves were examined using in vivo confocal microscopy (IVCM) with Heidelberg HRT3 Rostock Corneal Module. Patient 1 was a 70-year-old man with a right grade III NK following trigeminal nerve decompression for trigeminal neuralgia. Patient 2 was a 62-year-old man with a left grade II NK following a left-sided acoustic neuroma resection. The denervation time was 23 years for both patients. Following the MICN surgery, none of the patients achieved sustained improvement in the corneal sensation (though patient 1 achieved a transient improvement in central corneal sensation to 20mm at 4 months' postoperative before returning to 0mm at 6 months' postoperative). IVCM did not reveal any changes in the corneal nerve density and morphology post-MICN. Conclusions and Importance: Based on our observations and the literature, we postulate that long denervation time, proximal injury to the trigeminal nerve and older patient age may serve as poor prognostic factors for MICN. As CN is being increasingly adopted in clinical practice for treating NK, understanding of these potential factors will facilitate better risk-benefit stratification and patient counselling. Future larger studies are required to elucidate these findings.

An Active Duty Sailor With Worsening Headaches and Blurry Vision.

Headaches are a typical presentation to a military medical department or emergency room. Having a broad differential diagnosis and utilizing a thorough physical exam can assist providers in honing down the list of pathology and in identifying potentially life-threatening causes of cephalgia such as intracranial tumors. In this case, a 27-year-old man presented with progressive headaches along with vision changes for the preceding 2-3 months. On initial physical exam, he was found to have bilateral papilledema using a panoptic ophthalmoscope, confirmed after sending the patient to optometry. Neurology evaluated him and found a pineoblastoma on MRI. He underwent eventual neurosurgical debulking and radiation. The highlight of this case is the critical history components along with physical exam techniques that can assist providers in the identification of life-threatening causes of a headache. Direct ophthalmoscopy was vital in this case to encourage referral for further management. In selected studies, emergency medicine providers performed ophthalmoscopy in 14% of patients, with roughly 10% of those patients having erroneous findings. Another study showed that 13% of all cases presenting to a large academic center had fundoscopic findings that were important to the final diagnosis.

Corneal Neurotization for Neurotrophic Keratopathy: Clinical Outcomes and In Vivo Confocal Microscopic and Histopathological Findings.

PURPOSE: To describe the long-term outcomes and in vivo confocal microscopic (IVCM) and histopathological findings after corneal neurotization surgery. METHODS: We included 2 patients who underwent corneal neurotization surgery for severe unilateral neurotrophic keratopathy secondary to cerebellopontine angle meningioma. Corneal sensation was measured using the Cochet-Bonnet esthesiometer (CBE) (0-60 mm). IVCM was performed using the Heidelberg HRT3 Rostock Corneal Module. Histopathological examination was performed on the excised corneoscleral disc of patient 2. RESULTS: In patient 1, corneal sensation improved from 0 mm preoperatively to 60 mm in all 4 quadrants by 2 years postoperatively and was maintained at 5 years postoperatively with identifiable subbasal and stromal corneal nerves on IVCM. In patient 2, corneal sensation improved from 0 mm preoperatively to 10 mm in 3 quadrants (9 months postoperatively) but returned to 0 mm in all quadrants by 2 years postoperatively. IVCM failed to identify any subbasal and stromal corneal nerves. At 5 years postoperatively, evisceration was performed to ameliorate uncontrolled and persistent ocular pain and poor cosmesis. Histopathological examination of the excised corneoscleral disc confirmed the presence of normal-sized, central corneal stromal nerve fascicles but without direct continuity with the transplanted perilimbal nerve bundles. CONCLUSIONS: Our study elucidates the mechanism of corneal neurotization surgery at a cellular level. Although only 1 patient achieved long-term improvement in corneal sensation postoperatively, the findings on IVCM and histopathological examination suggest that partial regeneration/maintenance of corneal nerves after corneal neurotization surgery is likely attributed to the paracrine neurotrophic support, instead of direct sprouting, from the perilimbal transplanted nerve fascicles.

Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) is the commonest skin cancer in the white population. It is traditionally treated by surgical excision (SE) or by Mohs micrographic surgery (MMS). OBJECTIVES: The objective of this review was to compare the effectiveness, cost, complications and acceptability of periocular BCCs when operated by MMS or SE. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2014), EMBASE (January 1980 to February 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 February 2014. SELECTION CRITERIA: We planned to include only randomised controlled trials (RCTs) comparing SE with MMS for treatment of periocular BCC. DATA COLLECTION AND ANALYSIS: We did not find any studies that met the inclusion criteria for this review. MAIN RESULTS: We did not find any studies that met the inclusion criteria for this review and hence none were included for analysis. Results of non-randomised studies describing the individual techniques are reported. AUTHORS' CONCLUSIONS: No reliable conclusions could be reached regarding which method of treatment (SE or MMS) resulted in a lower recurrence or complication rate for periocular BCC. No studies were found comparing the cost of either method directly. High quality RCTs are therefore needed to improve the evidence base for the management of this condition.

The roots of predictivism.

In The Paradox of Predictivism (2008, Cambridge University Press) I tried to demonstrate that there is an intimate relationship between predictivism (the thesis that novel predictions sometimes carry more weight than accommodations) and epistemic pluralism (the thesis that one important form of evidence in science is the judgments of other scientists). Here I respond to various published criticisms of some of the key points from Paradox from David Harker, Jarret Leplin, and Clark Glymour. Foci include my account of predictive novelty (endorsement novelty), the claim that predictivism has two roots, the prediction per se and predictive success, and my account of why Mendeleev's predictions carried special weight in confirming the Periodic Law of the Elements.

Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) is the commonest skin cancer in the white population. It is traditionally treated by surgical excision (SE) or by Mohs micrographic surgery (MMS).   OBJECTIVES: The objective of this review was to compare the effectiveness, cost, complications and acceptability of periocular BCCs when operated by MMS or SE. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 11), MEDLINE (January 1950 to November 2011), EMBASE (January 1980 to November 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 23 November 2011. SELECTION CRITERIA: We planned to include only randomised controlled trials (RCTs) comparing SE with MMS for treatment of periocular BCC. DATA COLLECTION AND ANALYSIS: We did not find any studies that met the inclusion criteria for this review. MAIN RESULTS: We did not find any studies that met the inclusion criteria for this review and hence none were included for analysis. Results of non-randomised studies describing the individual techniques are reported. AUTHORS' CONCLUSIONS: No reliable conclusions could be reached regarding which method of treatment (SE or MMS) resulted in a lower recurrence or complication rate for periocular BCC. No studies were found comparing the cost of either method directly.   High quality RCTs are therefore needed to improve the evidence base for the management of this condition.

Chronic kidney disease management in an academic internal medicine clinic.

OBJECTIVE: We sought to evaluate the current state of chronic kidney disease (CKD) management in our academic internal medicine clinic. METHODS: A retrospective review was carried out involving all patients with laboratory evidence of CKD enrolled in our clinic. We evaluated the rate of CKD recognition as well as compliance with standard guidelines. We further subdivided our results based on physician training level, presence of diabetes, recognition of CKD, age, and race. RESULTS: Factors that significantly improved recognition and treatment of CKD in our study included presence of diabetes (p < 0.001), black race (p = 0.013), younger age (p = 0.004), and treatment by a resident physician (p = 0.009). Recognition of stage 3 CKD was associated with significant increases in urine protein analysis (p < 0.001) and nephrology consultation (p < 0.001). CONCLUSION: Chronic kidney disease remains under-recognized and undertreated despite well-publicized guidelines and widespread use of routine eGFR reporting.

Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) is the commonest skin cancer in the white population. It is traditionally treated by surgical excision (SE) or by Mohs micrographic surgery (MMS). OBJECTIVES: The objective of this review was to compare the effectiveness, cost, complications and acceptability of periocular BCCs when operated by MMS or SE. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library, Issue 4, 2008), MEDLINE (January 1950 to January 2009) and EMBASE (January 1980 to January 2009). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 12 January 2009. SELECTION CRITERIA: We planned to include only randomised controlled trials (RCTs) comparing SE with MMS for treatment of periocular BCC. DATA COLLECTION AND ANALYSIS: We did not find any studies that met the inclusion criteria for this review. MAIN RESULTS: We did not find any studies that met the inclusion criteria for this review and hence none were included for analysis. Results of non-randomised studies describing the individual techniques are reported. AUTHORS' CONCLUSIONS: No reliable conclusions could be reached regarding which method of treatment (SE or MMS) resulted in a lower recurrence or complication rate for periocular BCC. No studies were found comparing the cost of either method directly. High quality RCTs are therefore needed to improve the evidence base for the management of this condition.

Epiphora with eyelid laxity.

PURPOSE: To determine the efficacy of lower lid tightening procedures in the management of epiphora due to eyelid laxity. METHODS: Retrospective audit of 75 eyes in 49 patients with lid laxity and no nasolacrimal obstruction, who underwent lower lid tightening procedures for epiphora between November 2001 and June 2003. Relief from epiphora was assessed at the last clinic visit following surgery and by telephone interview in March-April 2004. RESULTS: Complete relief from epiphora persisted in 47 eyes (62.6%) as compared with 53 eyes (70.6%) at one month, and partial relief persisted in a further six eyes (8%). Eleven eyes (14.6%) with complete and five eyes (6.7%) with partial relief at discharge had recurrence of symptoms at follow-up. Mean follow-up time was 16.9 months. There was no statistically significant difference in relief between those with lateral and medial epiphora. CONCLUSIONS: Lid tightening surgery is useful in alleviating epiphora in a significant number of patients with lid laxity but the effect does not always last.

Secondary orbital implants after evisceration: a new conjunctiva-sparing technique.

PURPOSE: To describe a new conjunctiva-sparing technique for secondary orbital implantation after evisceration. METHODS: Two patients with conjunctival cicatrization and a volume-deficient anophthalmic socket had implantation of an intraconal biointegratable implant. This was placed through a lateral canthal approach, after temporary disinsertion of the lateral rectus, thereby avoiding further injury to the conjunctiva. RESULTS: A good surgical outcome was achieved in both patients. There were no intraoperative or postoperative complications, and both have remained stable for nearly 2 years. CONCLUSIONS: Secondary intraconal implantation through the lateral canthal approach is safe and effective and suitable for patients in whom it is desirable to avoid a conjunctival incision.

Neodymium:yttrium-aluminum-garnet capsulotomy and intraocular pressure in pseudophakic patients with glaucoma.

OBJECTIVE: To determine the 1- and 3-hour changes in intraocular pressure after neodymium:yttrium-aluminum-garnet (Nd:YAG) capsulotomy in pseudophakic patients with glaucoma and to determine the effect of acetazolamide and apraclonidine on these changes. DESIGN: Randomized controlled trial. PARTICIPANTS: Pseudophakic patients with glaucoma requiring Nd:YAG posterior capsulotomy (n = 76). INTERVENTION: Patients undergoing Nd:YAG posterior capsulotomy were randomly allocated to receive no therapy, oral acetazolamide (250 mg), or topical apraclonidine 1% within 1 hour before capsulotomy. MAIN OUTCOME MEASURES: Intraocular pressures 1 and 3 hours after laser therapy were recorded. RESULTS: Data were available for 76 eyes in 76 patients. Twenty-nine patients received no therapy; 24, oral acetazolamide; and 23, apraclonidine. One fifth (6/29) of patients with glaucoma developed a pressure rise of > or =5 mmHg if untreated, and 3% (1/29) developed a pressure rise of >10 mmHg. In comparison, no patients in the acetazolamide group developed a pressure rise of > or =5 mmHg (P = 0.02), and 1 of 24 in the apraclonidine group (P = 0.08) developed such a pressure rise, with none developing a pressure rise of >10 mmHg. When comparing all treated with nontreated, a reduction in the proportion with pressure rise was found (P = 0.01). All of the patients who developed a pressure rise of > or =5 mmHg did so within the first hour. CONCLUSIONS: In the absence of therapy, clinically significant post-Nd:YAG pressure rises occur in one fifth of patients with glaucoma undergoing capsulotomy. Oral acetazolamide and topical apraclonidine reduce the frequency and magnitude of pressure rises and are of comparable effectiveness. In this study, all clinically important pressure rises developed within the first hour.

Pyoderma gangrenosum of the ocular adnexa: a rare condition with characteristic clinical appearances.

PURPOSE: To describe the clinical characteristics of periocular pyoderma gangrenosum and to highlight features that may encourage early diagnosis of this extremely rare condition. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS AND METHODS: Four patients with periocular pyoderma gangrenosum were treated in the Orbital Unit at Moorfields Eye Hospital over the course of a decade. MAIN OUTCOME MEASURES: Presenting clinical features, therapy, and outcome. RESULTS: Four patients (female) between the ages of 56 and 75 years (mean, 65 years; median, 64 years) sought treatment for slowly evolving, painful, unilateral blue-gray swellings of the pretarsal tissues of the lower (1 case), upper (1 case), or both eyelids (2 cases). The swelling progressed to frank tissue necrosis and loss of full-thickness eyelid, with patchy sparing of the lid margin or lashes; in some cases, there was a very distinctive preservation of the pretarsal marginal artery across full-thickness eyelid defects. The lid loss characteristically involved the lateral one third of the lower eyelid (3 of 4 lids), the central part of the upper eyelid (3 of 4 lids) and, in one case, extending into the postseptal tissues in the inferotemporal quadrant of the orbit. In 3 patients, the pyoderma, often associated with a positive serum rheumatoid factor (three of three cases where measured), responded well to systemic immunosuppression and eyelid repair was undertaken during the quiescent phase. In a single patient, relapsing disease led to loss of the eye as a result of involvement of the globe and deep orbital tissues. CONCLUSIONS: Although an extremely rare condition, periocular pyoderma gangrenosum has a typical clinical appearance, and early recognition and immunosuppression will reduce the ocular morbidity.