Epidural Blood Patch for the Treatment of Spontaneous Intracranial Hypotension: A Case Series.

BACKGROUND: Epidural blood patch (EBP) is frequently used for the treatment of spontaneous intracranial hypotension (SIH) and anesthesiologists are often involved in performing such procedures. However, the optimal technique and approach of EBP remains uncertain. METHODS: This case series included adult patients with SIH who underwent EBPs at London Health Science Centre, Ontario, Canada between 2010 and 2022. Demographics, clinical presentations, investigations, and EBP treatment details were collected and analyzed. Univariate analysis was used to investigate the association of the variables with the likelihood of EBP 1-month efficacy and the efficacy duration of EBP. RESULTS: The study included 36 patients with SIH who received at least 1 EBP. EBPs provided immediate relief in almost all patients, albeit with diminishing effects over time. The 1-month efficacy improved with increasing number of EBP attempts (P=0.032, Fisher exact test), though no particular EBP technique or volume of injectate was associated with better efficacy (P=0.38, Fisher exact test). Though permanent resolution of symptoms was observed in only 24 of 82 EBPs (29%), 24 of 36 patients (67%) had permanent symptom resolution following repeated EBPs. CONCLUSIONS: EBP is a promising treatment and symptomatic relief option in patients suffering from the debilitating symptoms of SIH. Tailored EBP techniques, including use of targeted higher volume EBP and a multi-level catheter guided technique for refractory cases, showed efficacy in our institutional setting. Despite its limitations, this study contributes valuable insights and experiences into the use of EBP for treatment of SIH.

Immediate Weightbearing after Modified Lapidus Arthrodesis Using a Medial Plate: A Retrospective Descriptive Cohort Study.

The modified Lapidus procedure has emerged as a versatile solution for various pedal pathologies, particularly hallux abducto valgus. There have been numerous modifications over time regarding fixation techniques, joint preparation methods, graft utilization, and weightbearing protocols. However, concerns persist regarding prolonged non-weightbearing postoperatively, prompting the need for alternative approaches. This retrospective descriptive cohort analysis assessed the outcomes of 40 feet from 34 patients who underwent the modified Lapidus procedure with a medial plating system, aimed to evaluate immediate weightbearing outcomes on union rate, fixation-related complications, and functional outcomes. Among the 40 feet, findings showed a 95% (38/40) union rate within 6 months, with 2.5% (1/40) experiencing delayed union and 2.5% (1/40) facing fixation-related complications. There is a single case of malunion in the cohort. Additionally, statistically significant improvements were observed across all domains of the Manchester-Oxford Foot Questionnaire at p < .001. These findings suggest immediate weightbearing as a potential alternative to traditional non-weightbearing protocols. However, the study's retrospective nature and lack of a comparative group warrant cautious interpretation. Further research is essential to validate these findings and refine postoperative care protocols. By challenging conventional practices, this study underscores the complexity of optimizing patient outcomes in modified Lapidus procedure management. Tailored approaches and prospective investigations are imperative for establishing definitive guidelines and enhancing surgical techniques in this domain.

The effects of programmed optical zones on achieved corneal refractive power with myopic astigmatism after small incision lenticule extraction (SMILE): a vector analysis.

PURPOSE: To evaluate the effects of different programmed optical zones (POZs) on achieved corneal refractive power (CRP) with myopic astigmatism after small incision lenticule extraction (SMILE). METHODS: In total, 113 patients (113 eyes) were included in this retrospective study. The eyes were divided into two groups according to POZ: group A (6.5, 6.6, and 6.7 mm, n = 59) and group B (6.8, 6.9, and 7.0 mm, n = 54). Fourier vector analysis was applied to evaluate the error values between the attempted and achieved corneal refractive power (CRP). Alpins vector analysis was used to calculate surgically induced astigmatism (SIA), difference vector (DV), magnitude of error (ME), and astigmatism correction index (ACI). Multivariate regression analysis was performed to assess potential factors associated with the error values. RESULTS: The error values in the group with large POZ were closer to zero, and significantly associated with the POZ at 2 and 4 mm of the cornea (ß = - 0.50, 95% confidence interval [CI] [- 0.80, - 0.20]; ß = - 0.37, 95% CI [- 0.63, - 0.10], P < 0.05, respectively). For the correction of astigmatism, the values of SIA, ME, and ACI were lower in group B than in group A (P < 0.05). The fitting curves between TIA and SIA were y = 0.83x + 0.19 (R2 = 0.84) and y = 1.05x + 0.04 (R2 = 0.90), respectively. CONCLUSIONS: Smaller POZs resulted in higher error values between the achieved- and attempted-CRP in the SMILE procedure, which should be considered when performing surgery.

The association between altered intestinal microbiome, impaired systemic and ocular surface immunity, and impaired wound healing response after corneal alkaline-chemical injury in diabetic mice.

Purpose: We aim to investigate the effect of sustained hyperglycemia on corneal epithelial wound healing, ocular surface and systemic immune response, and microbiome indices in diabetic mice compared to controls after alkaline chemical injury of the eye. Methods: Corneal alkaline injury was induced in the right eye of Ins2Akita (Akita) mice and wild-type mice. The groups were observed at baseline and subsequently days 0, 3, and 7 after injury. Corneal re-epithelialization was observed under slit lamp with fluorescein staining using a cobalt blue light filter. Enucleated cornea specimens were compared at baseline and after injury for changes in cornea thickness under hematoxylin and eosin staining. Tear cytokine and growth factor levels were measured using protein microarray assay and compared between groups and time points. Flow cytometry was conducted on peripheral blood and ocular surface samples to determine CD3+CD4+ cell count. Fecal samples were collected, and gut microbiota composition and diversity pattern were measured using shotgun sequencing. Results: Akita mice had significantly delayed corneal wound healing compared to controls. This was associated with a reduction in tear levels of vascular endothelial growth factor A, angiopoietin 2, and insulin growth factor 1 on days 0, 3, and 7 after injury. Furthermore, there was a distinct lack of upregulation of peripheral blood and ocular surface CD3+CD4+ cell counts in response to injury in Akita mice compared to controls. This was associated with a reduction in intestinal microbiome diversity indices in Akita mice compared to controls after injury. Specifically, there was a lower abundance of Firmicutes bacterium M10-2 in Akita mice compared to controls after injury. Conclusion: In diabetic mice, impaired cornea wound healing was associated with an inability to mount systemic and local immune response to ocular chemical injury. Baseline and post-injury differences in intestinal microbial diversity and abundance patterns between diabetic mice and controls may potentially play a role in this altered response.

Optimized Artificial Intelligence for Enhanced Ectasia Detection Using Scheimpflug-Based Corneal Tomography and Biomechanical Data.

PURPOSE: To optimize artificial intelligence (AI) algorithms to integrate Scheimpflug-based corneal tomography and biomechanics to enhance ectasia detection. DESIGN: Multicenter cross-sectional case-control retrospective study. METHODS: A total of 3886 unoperated eyes from 3412 patients had Pentacam and Corvis ST (Oculus Optikgeräte GmbH) examinations. The database included 1 eye randomly selected from 1680 normal patients (N) and from 1181 "bilateral" keratoconus (KC) patients, along with 551 normal topography eyes from patients with very asymmetric ectasia (VAE-NT), and their 474 unoperated ectatic (VAE-E) eyes. The current TBIv1 (tomographic-biomechanical index) was tested, and an optimized AI algorithm was developed for augmenting accuracy. RESULTS: The area under the receiver operating characteristic curve (AUC) of the TBIv1 for discriminating clinical ectasia (KC and VAE-E) was 0.999 (98.5% sensitivity; 98.6% specificity [cutoff: 0.5]), and for VAE-NT, 0.899 (76% sensitivity; 89.1% specificity [cutoff: 0.29]). A novel random forest algorithm (TBIv2), developed with 18 features in 156 trees using 10-fold cross-validation, had a significantly higher AUC (0.945; DeLong, P < .0001) for detecting VAE-NT (84.4% sensitivity and 90.1% specificity; cutoff: 0.43; DeLong, P < .0001) and a similar AUC for clinical ectasia (0.999; DeLong, P = .818; 98.7% sensitivity; 99.2% specificity [cutoff: 0.8]). Considering all cases, the TBIv2 had a higher AUC (0.985) than TBIv1 (0.974; DeLong, P < .0001). CONCLUSIONS: AI optimization to integrate Scheimpflug-based corneal tomography and biomechanical assessments augments accuracy for ectasia detection, characterizing ectasia susceptibility in the diverse VAE-NT group. Some patients with VAE may have true unilateral ectasia. Machine learning considering additional data, including epithelial thickness or other parameters from multimodal refractive imaging, will continuously enhance accuracy. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Wavefront aberrometry repeatability and agreement-A comparison between Pentacam AXL Wave, iTrace and OPD-Scan III.

INTRODUCTION: To compare intrasession agreement and repeatability of wavefront aberration measurements from three different aberrometers obtained using Hartmann-Shack, ray tracing and automated retinoscopy methods, as well as their interdevice agreement. METHODS: Three consecutive measurements were obtained using the Pentacam AXL Wave, the iTrace and the OPD-Scan III in 47 eyes of 47 patients. Wavefront refractions, root mean square of total aberrations (RMS total), RMS of higher-order aberrations (HOA) and second-, third- and fourth-order HOAs were exported for 4-mm pupils. Wavefront refractions were converted into vector components: M, J0 and J45 . Intrasession agreement and repeatability were evaluated using intraclass correlation coefficients (ICCs) and repeatability coefficients (RCs); interdevice agreement was assessed using the Bland-Altman method. RESULTS: The intrasession agreement and repeatability of RMS HOA were comparable between the three devices; both the Pentacam AXL Wave and the OPD-Scan III had better intrasession agreement and repeatability for the RMS total than the iTrace (p ≤ 0.02). Intrasession repeatability for the majority of second- and third-order aberrations was better on the Pentacam AXL Wave than on the iTrace (p ≤ 0.01) and OPD-Scan III (p ≤ 0.04), although their agreement and repeatability in spherical aberration were comparable (p ≥ 0.24). Significant systematic differences and proportional bias were detected for almost all refraction power vectors and Zernike coefficients among the three devices. CONCLUSIONS: In this study, all three devices provided good-to-excellent agreement for aberration measurements. Most of the individual Zernike's components were not exchangeable between different aberrometers. Their relative intrasession performance in agreement and repeatability varied significantly across different ocular aberration parameters.

Accelerated corneal collagen cross-linking in progressive keratoconus: Five-year results and predictors of visual and topographic outcomes.

Purpose: To analyze the 5-year results of accelerated corneal collagen crosslinking (CXL) for progressive keratoconus and identify preoperative characteristics predictive of visual and topographic outcomes. Methods: A prospective interventional case series. Nineteen eyes of 19 patients receiving accelerated CXL with settings of 18 mW/cm2 for 5 min were included. Clinical and topographic parameters were assessed. Linear regression and logistic regression were used to compare the R2 and odds ratio (OR), respectively, between baseline characteristics and postoperative outcomes. Results: Corrected distance visual acuity (CDVA) remained stable from 0.28 ± 0.21 to 0.25 ± 0.18 logMAR (P = 0.486). The mean cylindrical refraction was stable (P = 0.119). The maximal keratometry (Kmax) decreased from 61.99 ± 10.37 to 59.25 ± 7.75 D (P < 0.001), flattening in the flattest and steepest meridians and mean keratometry were also observed (P ≤ 0.040). The mean anterior elevation at the apex reduced from 21.42 ± 16.69 to 18.53 ± 12.74 µm (P = 0.013) and changes in posterior elevation were non-significant (P = 0.629). Preoperative Kmax best predicted the postoperative change in Kmax (R2 = 0.55, P < 0.001) compared to the other baseline characteristics (P ≤ 0.028), whereas preoperative CDVA was the only significant predictor of postoperative change in CDVA (R2 = 0.41, P = 0.003). Accelerated CXL is less likely to fail in eyes with a steeper preoperative Kmax (OR = 0.74, P = 0.040) or greater posterior elevation at the apex (OR = 0.91, P = 0.042). Conclusion: Kmax significantly decreased following accelerated CXL. Eyes with worse preoperative CDVA and higher Kmax were more likely to have an improvement in visual acuity and corneal flattening.

Influence of Aerosol Chemical Composition on Condensation Sink Efficiency and New Particle Formation in Beijing.

Relatively high concentrations of preexisting particles, acting as a condensation sink (CS) of gaseous precursors, have been thought to suppress the occurrence of new particle formation (NPF) in urban environments, yet NPF still occurs frequently. Here, we aim to understand the factors promoting and inhibiting NPF events in urban Beijing by combining one-year-long measurements of particle number size distributions and PM2.5 chemical composition. Our results show that indeed the CS is an important factor controlling the occurrence of NPF events, with its chemical composition affecting the efficiency of the background particles in removing gaseous H2SO4 (effectiveness of the CS) driving NPF. During our observation period, the CS was found to be more effective for ammonium nitrate-rich (NH4NO3-rich) fine particles. On non-NPF event days, particles acting as CS contained a larger fraction of NH4NO3 compared to NPF event days under comparable CS levels. In particular, in the CS range from 0.02 to 0.03 s-1, the nitrate fraction was 17% on NPF event days and 26% on non-NPF event days. Overall, our results highlight the importance of considering the chemical composition of preexisting particles when estimating the CS and their role in inhibiting NPF events, especially in urban environments.

Combined accelerated collagen crosslinking and sub-Bowman's keratomileusis in high myopic eyes: a comparison between total ultraviolet energy dose.

AIM: To compare the safety, efficacy, and predictability outcomes of combined sub-Bowman's keratomileusis (thin flap laser in situ keratomileusis [LASIK]) and accelerated crosslinking (CXL) using two different irradiation durations. METHODS: A retrospective comparative study of patients with percent tissue altered ≥35%, undergoing simultaneous CXL during sub-Bowman's keratomileusis were recruited. Following riboflavin application, they underwent ultraviolet-A (UVA) irradiation (18 mW/cm2) for either 2 min (total energy 2.16 J/cm2) or 3 min (total energy 3.24 J/cm2). Visual and refractive outcomes were compared between follow-up visits during the first year postoperatively. Demarcation line and endothelial cell count were evaluated, respectively, at 1 and 3 months postoperatively. RESULTS: The baseline characteristics were similar between the 40 eyes/patients treated using the 2-min protocol and the 33 eyes/patients treated with the 3-min protocol (p ≥ .114). Uncorrected distance visual acuity and corrected distance visual acuity were significantly better for eyes treated with the shorter irradiation protocol on Day 1 (p ≤ .030) and Month 1 (p ≤ .040) postoperatively; these differences diminished by Month 3 (p ≥ .070). Likewise, the efficacy index was higher during the first postoperative week for the 2-min protocol (p ≤ .043). At 1 year, the proportion of eye attaining within 0.5 D of target refraction was 80.0% and 84.8% for the 2-min and 3-min protocols, respectively (p = .590). The corresponding corneal stromal demarcation line depth and endothelial cell density changes were comparable between the two groups (p = .311 and 0.899, respectively). CONCLUSIONS: A comparable volume of crosslinked corneal tissue can be achieved by using a shorter UVA irradiation duration. Additional duration of UVA irradiation could lead to delay in visual rehabilitation after simultaneous sub-Bowman's keratomileusis and CXL.

The 2018 European heatwave led to stem dehydration but not to consistent growth reductions in forests.

Heatwaves exert disproportionately strong and sometimes irreversible impacts on forest ecosystems. These impacts remain poorly understood at the tree and species level and across large spatial scales. Here, we investigate the effects of the record-breaking 2018 European heatwave on tree growth and tree water status using a collection of high-temporal resolution dendrometer data from 21 species across 53 sites. Relative to the two preceding years, annual stem growth was not consistently reduced by the 2018 heatwave but stems experienced twice the temporary shrinkage due to depletion of water reserves. Conifer species were less capable of rehydrating overnight than broadleaves across gradients of soil and atmospheric drought, suggesting less resilience toward transient stress. In particular, Norway spruce and Scots pine experienced extensive stem dehydration. Our high-resolution dendrometer network was suitable to disentangle the effects of a severe heatwave on tree growth and desiccation at large-spatial scales in situ, and provided insights on which species may be more vulnerable to climate extremes.

A Systematic Review on the Association Between Tear Film Metrics and Higher Order Aberrations in Dry Eye Disease and Treatment.

We systematically reviewed published research on dry eye disease and its association with higher order aberrations (HOAs). The purpose of this review was to first determine if an association between tear film metrics and HOAs exists and second to determine if the treatment of dry eyes can improve tear film metrics and HOAs together. A search was conducted in Entrez PubMed on 25 April 2021 using the keywords "higher order aberrations" and "dry eye". The initial search yielded 61 articles. After publications were restricted to only original articles measuring HOA outcomes in patients with dry eye, the final yield was 27 relevant articles. Of these 27 papers, 12 directly looked at associations and correlations between dry eyes and HOA parameters. The remaining 15 studies looked at dry eye interventions and HOA outcomes and parameters. There is clear evidence demonstrating that dry eyes and HOAs have an association, and that the tear film is one of the most important factors in this relationship. There is also a direct correlation between tear film metrics and HOAs. Improvements in HOAs with dry eye interventions provide further evidence to support the intricate relationship between the two. Despite the clear association between HOAs and dry eye disease, further research is still required in the realm of clinical application as dry eye interventions vary depending on many factors, including patient severity and eye drop viscosity.