Selective laser trabeculoplasty for primary open-angle glaucoma patients younger than 40 years.

OBJECTIVE: To evaluate the efficacy of selective laser trabeculoplasty (SLT) among patients with juvenile-onset primary open-angle glaucoma (JOAG). METHODS: Patients diagnosed with JOAG who were not controlled on medical therapy were offered a trial of SLT. The patients were followed up prospectively for 1, 3, 6, and 12 months postlaser to evaluate the efficacy of SLT as second-line therapy. Success was defined as an intraocular pressure (IOP) reduction of ≥20% at 12 months without the need for further medication, laser, or surgery. Factors associated with success/failure, prelaser IOP, age, and angle dysgenesis on gonioscopy were analysed. RESULTS: The average prelaser IOP in these JOAG eyes (n = 30) was 25.3 ± 6.5 mm Hg, which reduced to 17.3 ± 5.8 mm Hg at 12 months (p = 0.01). All patients were of Indian ethnicity. Out of 30 eyes, at 12 months post-SLT, 13 (43%) eyes had at least a 20% reduction in IOP. In the eyes that achieved success, the average reduction of IOP was 37.6%. There was no difference in the prelaser IOP between those with success (25.5 ± 5.6 mm Hg) and those that failed (25.1 ± 8 mm Hg; p = 0.8), nor was there a difference in the mean age between successful cases (34.4 ± 9.4 years) and failures (31.6 ± 8.9 years; p = 0.4). However, those without angle dysgenesis were 4 times (CI 1.1-15.2) more likely to succeed with SLT than those with angle dysgenesis (p = 0.03). CONCLUSIONS: A significant proportion of patients with JOAG can benefit from an IOP reduction after SLT. Those with gonioscopically normal-appearing angles are more likely to respond to SLT.

Outcomes of Patients Undergoing Primary Fontan Operation Beyond First Decade of Life.

OBJECTIVES: Studies on older patients undergoing primary Fontan operation (FO) are limited, with conflicting results. We review our experience with these patients beyond the first decade of life. PATIENTS AND METHODS: Between January 2000 and December 2014, a total of 105 patients ≥10 years of age (mean 15.6 ± 4.9, range 10-31, median 15 years) underwent primary FO without a prior bidirectional superior cavopulmonary anastomosis (Bidirectional Glenn [BDG]). Mean preoperative New York Heart Association (NYHA) class was 2.2 ± 0.57. RESULTS: Operative procedure was extra-cardiac FO in 62 patients (8 were fenestrated). Forty-three had a lateral tunnel FO (26 were fenestrated). There were 11 (10.5%) early deaths. Fourteen of the 94 early survivors experienced prolonged pleural effusions, 7 had arrhythmias, and 2 had thromboembolic events. Two patients underwent Fontan takedown. On univariate analysis, NYHA functional class III, mean pulmonary artery (PA) pressure ≥15 mm Hg, hematocrit ≥60%, preoperative ventricular dysfunction, and atrioventricular valve regurgitation (AVVR) were associated with early mortality. Median follow-up was 78 (mean 88.9 ± 6.3) months. In 94 survivors, 6 (6.4%) late deaths were encountered. At last follow-up, 81 (86.2%) survivors were in NYHA class I. Actuarial survival was 84.7% ± 3.7% at 5, 10, and 15 years. CONCLUSION: Carefully selected adolescents and young adults can safely undergo the primary FO. However, persistent pleural effusions, arrhythmias, thromboembolic events, and the need for reoperation mandate regular follow-up in such patients. Preoperative NYHA functional class III, mean PA pressure ≧ 15 mm Hg, hematocrit ≥ 60%, ventricular dysfunction, and AVVR were associated with early mortality, suggesting that primary FO should be avoided in such patients.

Long-Term Evaluation of Specular Microscopic Changes Following Nd: YAG Iridotomy in Chronic Primary Angle-Closure Glaucoma Eyes.

AIM: The aim of this study was to evaluate specular microscopy of chronic primary angle-closure glaucoma (CPACG) eyes at least 1 year after Nd:YAG iridotomy, and compare them with CPACG eyes without an iridotomy and age-matched, normal eyes. PATIENTS AND METHOD: Consecutive patients of CPACG at the Glaucoma service were screened. All patients underwent slit-lamp biomicroscopy, +90 D examination, and applanation tonometry. A total of 100 eyes of 100 consecutive patients of CPACG with an Nd:YAG iridotomy performed ≥1 year before, who met all inclusion/exclusion criteria, 60 consecutive CPACG eyes without an iridotomy, and 60 age and refraction-matched control eyes were enrolled. A specular microscopy was performed in one eye of each patient by an observer masked to diagnosis. RESULTS: CPACG patients had a mean age of 62±8 years, a mean intraocular pressure of 18±5.3 mm Hg, a mean specular count of 2536±224 cells/mm, and mean duration after iridotomy of 3.2±2 years. There was a significant correlation of specular endothelial counts with age (r=-0.39; P<0.001) and interval after iridotomy (r=-0.25; P=0.01). CPACG eyes without an iridotomy had a mean age of 62±5 years and a mean specular count of 2469±199 cells/mm. Normal control eyes with a mean age of 61±6 years had a mean specular count of 2729±299 cells/mm. There was no significant difference in specular count between CPACG eyes with or without an iridotomy (P=0.19); however, both CPACG groups had a specular count significantly lower than controls (P=0.01 and 0.02, respectively). There was no statistically significant difference seen in polymegathism (coefficient of variation) and pleomorphism (% of hexagonal cells) in endothelial cells among the 3 groups. CONCLUSIONS: An Nd:YAG iridotomy in CPACG eyes did not lead to any significant changes in central corneal specular microscopy in the long term as compared with patients who did not undergo iridotomy. Eyes with CPACG, without and after an iridotomy, had a lower specular count compared with age-matched controls.

Incidence of postoperative nausea and vomiting following gynecological laparoscopy: A comparison of standard anesthetic technique and propofol infusion.

OBJECTIVE: To determine the safety, efficacy, and feasibility of propofol-based anesthesia in gynecological laparoscopies in reducing incidences of postoperative nausea and vomiting compared to a standard anesthesia using thiopentone/isoflurane. DESIGN: Randomized single-blind (for anesthesia techniques used) and double-blind (for postoperative assessment) controlled trial. SETTING: Operation theater, postanesthesia recovery room, teaching hospital. PATIENTS: Sixty ASA (American Society of Anesthesiologists) I and II female patients (aged 20-60 years) scheduled for gynecological laparoscopy were included in the study. INTERVENTIONS: Patients in Group A received standard anesthesia with thiopentone for induction and maintenance with isoflurane-fentanyl, and those in Group B received propofol for induction and maintenance along with fentanyl. All patients received nitrous oxide, vecuronium, and neostigmine/glycopyrrolate. No patient received elective preemptive antiemetic, but patients did receive it after more than one episode of vomiting. MEASUREMENTS: Assessment for incidence of postoperative nausea and vomiting as well as other recovery parameters were carried out over a period of 24 hours. MAIN RESULTS: Six patients (20%) in Group A and seven patients (23.3%) in Group B experienced nausea. Two patients (6.66%) in Group B had vomiting versus 12 (40%) in Group A (p<0.05). Overall, the incidence of emesis was 60% and 30% in Groups A and B, respectively (p<0.05). All patients in Group B had significantly faster recovery compared with those in Group A. No patient had any overt cardiorespiratory complications. CONCLUSION: Propofol-based anesthesia was associated with significantly less postoperative vomiting and faster recovery compared to standard anesthesia in patients undergoing gynecological laparoscopy.

Long-term outcomes of glaucoma drainage devices for glaucoma post-vitreoretinal surgery with silicone oil insertion: a prospective evaluation.

PURPOSE: To evaluate long-term success of the Ahmed glaucoma valve (AGV) for refractory glaucoma after vitreoretinal surgery with silicone oil insertion. METHODS: Prospective non-comparative evaluation of patients who underwent AGV insertion for management of post-vitreoretinal surgery glaucoma, post-silicone oil removal. Intraocular pressure (IOP), visual acuity, and glaucomatous neuropathy status were evaluated preoperatively and at multiple follow-up visits postoperatively. Success, using Kaplan-Meier analysis, was determined at the 12-month follow-up visit and at the last follow-up. Factors associated with failure were analysed. RESULTS: Twenty-seven eyes of 27 patients with a mean age of 28.3 ± 15.2 years underwent a superior AGV implantation. The average follow-up after AGV implantation was 17.11 ± 8.36 months (range: 9-60 months). Kaplan-Meier survival analysis revealed a 62 % success at 12 months and 37 % at 5 years. A 48 % rate of complications was noted, 22 % of which were vision-threatening. Factors analysed, including patient age, interval between vitreoretinal surgery and silicone oil removal, interval between vitreoretinal surgery and AGV implantation, and phakic status, were not found to be associated with higher failure rates. CONCLUSION: Long-term success of AGV implantation for glaucoma after vitreoretinal surgery with silicone oil insertion is better than that reported for trabeculectomy, though complication rates remain high.

PERIPHERAL RETINAL DEGENERATIONS AND RHEGMATOGENOUS DETACHMENT IN PRIMARY CONGENITAL GLAUCOMA.

BACKGROUND: To determine the prevalence of peripheral retinal degenerations (PRD) and rhegmatogenous retinal detachment in patients with primary congenital glaucoma (PCG). METHODS: Records of all patients with PCG operated from year 2000 onwards were evaluated to look for the prevalence of rhegmatogenous retinal detachment. Of these, those children who were old enough to cooperate and had sufficient medial clarity were screened with an indirect ophthalmoscopy in a cross-sectional evaluation from 2010 to 2014. Peripheral retina was examined, and prevalence of PRD was estimated in this subset. For statistical purposes, only one eye of each patient was considered in this cross-sectional analysis. RESULTS: Of the 310 eyes (180 patients with PCG) operated from the year 2000 onwards, a rhegmatogenous retinal detachment was noted in 13 eyes (4%). Mean axial length of these eyes was 26.3 ± 3.2 mm (range, 19.8-34.7 mm). Among the eyes screened for PRD (n = 60), prevalence of pathologic PRD (lattices with/without atrophic holes and isolated holes/tears) was 15%. The average follow-up between glaucoma filtering surgery and the date of last examination was 8.55 ± 3.98 years (range, 5-20 years) in this subset. Mean axial length was significantly greater in eyes with pathologic PRD than in those without (28.1 ± 3.3 mm vs. 25.8 ± 2.6 mm; P = 0.01). For axial length ≥ 26 mm, the odds of having a pathologic PRD were 14.4 times more than those with axial length < 26 mm (P < 0.001; 95% confidence interval, 1.7-120.5). CONCLUSION: Prevalence of PRD among eyes with PCG is high. Peripheral retinal screening should be performed in eyes with PCG, especially those with axial lengths ≥ 26 mm.

Design and Validation of an Open-Source, Partial Task Trainer for Endonasal Neuro-Endoscopic Skills Development: Indian Experience.

BACKGROUND: Box trainers are ideal simulators, given they are inexpensive, accessible, and use appropriate fidelity. OBJECTIVE: The development and validation of an open-source, partial task simulator that teaches the fundamental skills necessary for endonasal skull-base neuro-endoscopic surgery. METHODS: We defined the Neuro-Endo-Trainer (NET) SkullBase-Task-GraspPickPlace with an activity area by analyzing the computed tomography scans of 15 adult patients with sellar suprasellar parasellar tumors. Four groups of participants (Group E, n = 4: expert neuroendoscopists; Group N, n =19: novice neurosurgeons; Group R, n = 11: neurosurgery residents with multiple iterations; and Group T, n = 27: neurosurgery residents with single iteration) performed grasp, pick, and place tasks using NET and were graded on task completion time and skills assessment scale score. RESULTS: Group E had lower task completion times and greater skills assessment scale scores than both Group N and R (P ≤ 0.03, 0.001). The performance of Groups N and R was found to be equivalent; in self-assessing neuro-endoscopic skill, the participants in these groups were found to have equally low pretraining scores (4/10) with significant improvement shown after NET simulation (6, 7 respectively). Angled scopes resulted in decreased scores with tilted plates compared with straight plates (30° P ≤ 0.04, 45° P ≤ 0.001). With tilted plates, decreased scores were observed when we compared the 0° with 45° endoscope (right, P ≤ 0.008; left, P ≤ 0.002). CONCLUSIONS: The NET, a face and construct valid open-source partial task neuroendoscopic trainer, was designed. Presimulation novice neurosurgeons and neurosurgical residents were described as having insufficient skills and preparation to practice neuro-endoscopy. Plate tilt and endoscope angle were shown to be important factors in participant performance. The NET was found to be a useful partial-task trainer for skill building in neuro-endoscopy.

Nocturnal cramps in patients with lumbar spinal canal stenosis treated conservatively: a prospective study.

STUDY DESIGN: Prospective cohort study with questionnaire. PURPOSE: To compare the treatment outcome of nocturnal leg cramps in lumbar spinal canal stenosis (LSCS) patients on conservative treatment with historical surgical cohorts and to determine the sensitivity and specificity as well as positive predictive value and negative predictive value of knee flexion test suggested for LSCS patient. OVERVIEW OF LITERATURE: True prevalence of nocturnal leg cramps in LSCS patients as well as the clinical outcome of its surgical treatment have been reported. METHODS: A questionnaire suggested from previous study with minor modifications was used in this study. Clinical data was collected. Knee flexion test was performed in two groups. RESULTS: The prevalence of nocturnal leg cramp was higher in the LSCS group compared to the control group (second group). In LSCS patients, 38 (88%) had improved leg cramps after the conservative treatment, 3 (6.97%) remained unchanged, and 2 (4.6%) had worsened leg cramps. Of the 43 patients, 21 (48.8%) had no disturbance to their activities of daily living. In the LSCS group, the sensitivity and specificity of the knee flexion test was 53.5% and 33.3%, respectively. The knee flexion test in the LSCS group had a positive predictive value and a negative predictive value of 65.71% and 23.1%, respectively. CONCLUSIONS: Our study demonstrated that nocturnal leg cramps were significantly more frequent in LSCS patients than in the control group.

New modified english and hindi oswestry disability index in low back pain patients treated conservatively in Indian population.

STUDY DESIGN: Prospective cohort study along with questionnaire. PURPOSE: To measure the correlation of the visual analogue score (VAS), with (Oswestry disability Index [ODI], version 2.1a) in English, and modified ODI (English and Hindi version). To validate translated version of the modified ODI in English version to Hindi. OVERVIEW OF LITERATURE: Conflicting evidence in literature regarding the ability for existing ODI score to accurately measure the pain associated disability. METHODS: One hundred and three patients conservatively treated for low back pain were enrolled in the study. The Pearson correlation coefficient for VAS and ODI along with the Cronbach α and test-retest reliability for Hindi version using the intraclass correlation coefficient was recorded. The new proposed translated Hindi version of ODI was carried out with established guidelines. RESULTS: The mean age in English and Hindi version of ODI was 53.5 years and 58.5 years, respectively. The gender ration was 21:24 in the English version and 35:23 in the Hindi version. The mean follow-up in English and Hindi version of ODI was 3.4 months and 50.27 months, respectively. The Cronbach coefficient α=0.7541 for English ODI and 0.9913 for Hindi ODI was recorded for the both modified versions. CONCLUSIONS: The new modified ODI is time saving and accurate, and it avoids the need to measure other scores and has stronger correlation with VAS score compared to the previous scores. We recommend this version for both English and Hindi speaking population as an assessment tool to measure the disability related to pain.

Effect of glaucoma on the quality of life of young patients.

PURPOSE: To evaluate the quality of life (QOL) of juvenile-onset primary open-angle glaucoma (JOAG) patients by using a utility-based assessment. METHODS: QOL using time-tradeoff utility values was analyzed in 70 JOAG patients and compared with 108 adult-onset POAG patients. The relationships of utility values to parameters like age at diagnosis, visual acuity, mean deviation, number of medications and surgery, duration of the disease, level of education, and socioeconomic status were assessed. RESULTS: The mean age at diagnosis of JOAG patients was 26 ± 9.8 years, whereas that of the adult onset POAG patients was 62 ± 11.2 years. Overall, there was a decrease in utility values with increasing age (r = -0.3; P < 0.001). The mean utility score among JOAG patients was (0.80 ± 0.18) significantly greater than among adult POAG patients (0.64 ± 0.28; P < 0.001). The differences in utility scores between JOAG and adult POAG patients were significant when adjusted for differences in better eye visual acuity, mean deviation, and the presence of systemic comorbidity among adults (P = 0.02). Among JOAG patients, those needing topical antiglaucoma medications and those with visual acuity worse than 6/12 in the better eye had lower utility values (P = 0.008 and P = 0.002, respectively). CONCLUSIONS: Utility values among glaucoma patients in the juvenile age group are better than those of adult POAG patients. Decreasing vision in the better eye and having to use medication decrease the utility scores among young patients with glaucoma.

Respiratory-triggered versus breath-hold diffusion-weighted MRI of liver lesions: comparison of image quality and apparent diffusion coefficient values.

OBJECTIVE: The purpose of our study was to compare respiratory-triggered and breath-hold diffusion-weighted liver MRI and to assess the agreement in the apparent diffusion co-efficient (ADC) values between the two sequences. MATERIALS AND METHODS: Forty-eight patients (27 men, 21 women; mean age, 45.2 years) with focal liver lesions underwent respiratory-triggered and breath-hold diffusion-weighted MRI (DWI) in addition to routine MRI. Both sequences had identical imaging parameters except for signal averages, which were 6 in respiratory-triggered and 2 in breath-hold sequences. A total of 92 lesions (maximum of three lesions per patient; 37 benign, 55 malignant) were evaluated. Lesions were confirmed by typical imaging appearance, histopathology, or follow-up. Signal-to-noise ratio (SNR) of the liver, contrast-to-noise ratio (CNR), and relative contrast ratio of the lesions were measured in each DWI sequence and were statistically compared using the Mann-Whitney U test. The ADC values of normal liver and each category of liver lesions in the two sequences were compared for agreement using Pearson's coefficient and reliability analysis scale. RESULTS: The SNR of the normal liver was significantly better on respiratory-triggered DWI than on breath-hold DWI. The mean CNR of metastases, hepatocellular carcinomas, and abscesses was significantly better in the respiratory-triggered DWI than in the breath-hold DWI sequences. The ADC values of liver and focal lesions measured by the two techniques showed good agreement. The SDs of the ADC values of normal liver were similar in the two sequences. CONCLUSION: Respiratory-triggered DWI should be preferred over breath-hold DWI for the evaluation of focal liver lesions because it provides better image quality and SNR without any compromise in the calculated ADC values.