Visual functioning and general health status in patients with uveitis.

OBJECTIVE: To measure the visual functioning and quality of life in patients with uveitis. METHODS: Consecutive adult patients with noninfectious uveitis were enrolled. The Medical Outcomes Study 36-Item Short Form (SF-36) and the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) were administered by a trained interviewer. Sociodemographic and clinical data were also collected. RESULTS: Seventy-six patients were enrolled. The overall NEI VFQ-25 score was significantly lower among patients with uveitis than in a normal reference group (P<.001). The SF-36 physical (PCS) and mental (MCS) component summary scores were also significantly lower among patients with uveitis than in the general US population (P<.007). Among patients with uveitis, visual acuity, binocular involvement, intensity of therapy, employment status, and PCS and MCS scores were all significantly associated with overall NEI VFQ-25 scores in multivariable analysis. Medical comorbidity, ocular comorbidity, and NEI VFQ-25 scores were significantly associated with PCS scores. Medical comorbidity and NEI VFQ-25 scores were significantly associated with MCS scores. Regression models including NEI VFQ-25 scores explained an additional 7% of the variance in PCS scores and 16% of MCS scores. Models including both PCS and MCS scores explained an additional 12% of the variance in NEI VFQ-25 scores. CONCLUSIONS: Patients with uveitis reported markedly poorer visual functioning and general health status than normal subjects. Patients with more severe uveitis have poorer visual functioning and general health status than patients with milder disease. Visual functioning and general health status measurement contribute complementary information and should both be performed in patients with uveitis to measure the effect of disease and its therapy on their quality of life.

Choroidal granulomas in systemic sarcoidosis.

PURPOSE: To evaluate the clinical course, including response to therapy, of patients with macular and peripapillary choroidal granulomas secondary to systemic sarcoidosis. METHODS: This is a retrospective case study and literature review. Nine patients with choroidal granulomas were identified. Eight patients had a tissue biopsy confirming sarcoidosis; one was diagnosed from clinical history and typical gallium scan. Ocular examinations included fundus examination, fluorescein angiography, and visual field examination. Eight patients had magnetic resonance imaging (MRI) scans looking for intracranial granulomas. Treatment consisted of oral prednisone in eight patients (one with concomitant subconjunctival triamcinolone); one patient received no treatment because of good vision and granuloma in the nasal retina. Variables studied included visual acuity (VA), response of granulomas to treatment, time to recurrence, and associated anterior segment findings. RESULTS: Eight of nine patients had a solitary lesion whereas one had multifocal involvement. The granulomas ranged in size from one half to four disk diameters. Eight patients had blurry vision; one was asymptomatic. All nine patients had hilar adenopathy and/or pulmonary parenchymal disease. No patient had nonocular neurologic symptoms and in eight patients who underwent MRI examination no intracranial granulomas were detected. Of the eyes that were treated (n = 8) all had decrease in the size of the choroidal mass at an average of 4 months of treatment. Two had complete resolution. Mean follow-up was 29.2 months. At the time of initial diagnosis only one patient had an active anterior uveitis. Five of nine patients had at least one recurrence. Mean time to recurrence was 7.6 months after discontinuing oral prednisone. The VA at presentation ranged from 20/30 to 20/300. Final VA was 20/30 or better in all patients. CONCLUSIONS: Choroidal granulomas related to systemic sarcoidosis respond well to oral corticosteroids. They may recur but good vision can be maintained. They are not typically associated with concomitant iritis and also do not appear to be associated with intracranial granulomas.

Clinical success and quality of life with brimonidine 0.2% or timolol 0.5% used twice daily in glaucoma or ocular t hypertension: a randomized clinical trial. Brimonidine Outcomes Study Group I.

PURPOSE: To compare the clinical success rates and quality of life impact of brimonidine 0.2% with timolol 0.5% in newly diagnosed patients naive to glaucoma therapy. METHODS: A prospective, multicenter, randomized, double-masked, clinical effectiveness trial in which the clinical outcomes of twice daily brimonidine tartrate 0.2% were compared with those of timolol maleate 0.5% in patients with glaucoma and' ocular hypertension was conducted. Two hundred nineteen patients were enrolled--111 in the brimonidine group and 108 in the timolol group. Patients instilled their study medications twice daily for 4 months. Factors for determining clinical success were reduction of intraocular pressure (IOP), safety, and adverse events. Quality of life effects were assessed with the SF-36 Health Survey and Glaucoma Disability Index questionnaires. RESULTS: Clinical success was 71% (75/106) with brimonidine and 70% (73/105) with timolol as initial treatment. The overall mean decrease in IOP was 6.5 mm Hg with brimonidine and 6.2 mm Hg with timolol. Few patients reported a specific adverse event and, with the exception of a slightly higher rate of ocular burning and stinging in the brimonidine group, there were no significant between-group differences. No significant chronotropic effects on the heart were seen with brimonidine, while small but significant mean decreases in heart rate were seen at months 1 and 4 with timolol. Mean systolic and diastolic blood pressure remained relatively stable in both groups. Quality of life remained stable, with no significant between-group differences. CONCLUSIONS: As a first-line agent for the treatment of glaucoma and ocular hypertension, brimonidine has clinical effectiveness equivalent to timolol, but with less chronotropic effect on the heart. Brimonidine is a viable alternative to timolol for first-line therapy in glaucoma and ocular hypertension.

Reliability and validity of the Ocular Surface Disease Index.

OBJECTIVE: To evaluate the validity and reliability of the Ocular Surface Disease Index (OSDI) questionnaire. METHODS: Participants (109 patients with dry eye and 30 normal controls) completed the OSDI, the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), the McMonnies Dry Eye Questionnaire, the Short Form-12 (SF-12) Health Status Questionnaire, and an ophthalmic examination including Schirmer tests, tear breakup time, and fluorescein and lissamine green staining. RESULTS: Factor analysis identified 3 subscales of the OSDI: vision-related function, ocular symptoms, and environmental triggers. Reliability (measured by Cronbach alpha) ranged from good to excellent for the overall instrument and each subscale, and test-retest reliability was good to excellent. The OSDI was valid, effectively discriminating between normal, mild to moderate, and severe dry eye disease as defined by both physician's assessment and a composite disease severity score. The OSDI also correlated significantly with the McMonnies questionnaire, the National Eye Institute Visual Functioning Questionnaire, the physical component summary score of the Short Form-12, patient perception of symptoms, and artificial tear usage. CONCLUSIONS: The OSDI is a valid and reliable instrument for measuring the severity of dry eye disease, and it possesses the necessary psychometric properties to be used as an end point in clinical trials.

Intraocular pressure elevation after simple pars plana vitrectomy.

PURPOSE: The purpose of the study is to determine the incidence, timing, and severity of variability in the intraocular pressures (IOPs) from baseline after simple pars plana vitrectomy. METHODS: A prospective study was performed in 25 consecutive patients undergoing simple pars plana vitrectomy. Intraocular pressures were measured before surgery, immediately after surgery, and then at 2, 4, 6, 12, and 24 hours after surgery. RESULTS: The mean IOP was elevated significantly 2 hours after surgery when compared with the mean immediate postoperative IOP (30.3 mmHg +/- 11.0 mmHg vs. 17.4 mmHg +/- 7.0 mmHg, P < 0.001). A steady decline was seen at all succeeding timepoints. The 24-hour mean (17.3 mmHg +/- 4.3 mmHg, P = 0.923) was similar to baseline. Ninety-two percent of eyes had a 2-hour postoperative IOP that was higher than the IOP at the completion of surgery. Forty percent of patients required medical management for IOP greater than or equal to 30 mmHg. CONCLUSIONS: Significant IOP elevation can occur after simple pars plana vitrectomy. The optimal time for detecting the pressure rise during the first 24 hours is 2 hours after surgery.

Prophylaxis for stress-related gastrointestinal hemorrhage: a cost effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to the intensive care unit. DESIGN: Decision model of the cost and efficacy of sucralfate and cimetidine, two commonly used drugs for prophylaxis of stress-related hemorrhage. Outcome estimates were based on data from published studies. Cost data were based on cost of medications and costs of treatment protocols at our institutions. MEASUREMENTS AND MAIN RESULTS: The marginal cost-effectiveness of prophylaxis, as compare with no prophylaxis, was calculated separately for sucralfate and cimetidine and expressed as cost per bleeding episode averted. An incremental cost-effectiveness analysis was subsequently employed to compare the two agents. Sensitivity analyses of the effects of the major clinical outcomes on the cost per bleeding episode averted were performed. At the base-case assumptions of 6% risk of developing stress-related hemorrhage and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleeding episode averted. The cost per bleeding episode averted was highly dependent on the risk of hemorrhage and, to a lesser degree, on the efficacy of sucralfate prophylaxis, ranging from a cost per bleeding episode averted of $103,725 for low-risk patients to cost savings for very high-risk patients. The cost per bleeding episode averted increased significantly if the risk of nosocomial pneumonia was included in the analysis. The effect of pneumonia was greater for populations at low risk of hemorrhage. Assuming equal efficacy, the cost per bleeding episode averted of cimetidine was 6.5-fold greater than the cost per bleeding episode averted of sucralfate. CONCLUSIONS: The cost of prophylaxis in patients at low risk of stress-related hemorrhage is substantial, and may be prohibitive. Further research is needed to identify patient populations that are at high risk of developing stress-related hemorrhage, and to determine whether prophylaxis increases the risk of nosocomial pneumonia.

Design considerations of CareWindows, a Windows 3.0-based graphical front end to a Medical Information Management System using a pass-through-requester architecture.

The Care Windows development project demonstrated the feasibility of an approach designed to add the benefits of an event-driven, graphically-oriented user interface to an existing Medical Information Management System (MIMS) without overstepping economic and logistic constraints. The design solution selected for the Care Windows project incorporates three important design features: (1) the effective de-coupling of severs from requesters, permitting the use of an extensive pre-existing library of MIMS servers, (2) the off-loading of program control functions of the requesters to the workstation processor, reducing the load per transaction on central resources and permitting the use of object-oriented development environments available for microcomputers, (3) the selection of a low end, GUI-capable workstation consisting of a PC-compatible personal computer running Microsoft Windows 3.0, and (4) the development of a highly layered, modular workstation application, permitting the development of interchangeable modules to insure portability and adaptability.

Medical Information Management System (MIMS) CareWindows.

The demonstration of MIMS/CareWindows will include: (1) a review of the application environment and development history, (2) a demonstration of a very large, comprehensive clinical information system with a cost effective graphic user server and communications interface.

Cocaine-induced hepatonephrotoxicity: a case report.

Hepatotoxicity due to cocaine has been well described in animal models. There are few reports on cocaine-induced hepatic injury in humans; however, its link to rhabdomyolysis and renal failure is better known. We report a case of reversible acute hepatonephrotoxicity associated with recreational cocaine use. The proposed mechanisms responsible for its hepatic and renal toxicity are reviewed.