Ocular pulse amplitude in patients with descemet stripping endothelial keratoplasty.

PURPOSE: To study the relationship of ocular pulse amplitude (OPA) and intraocular pressure (IOP) in eyes that have undergone successful Descemet stripping endothelial keratoplasty (DSEK). PATIENTS AND METHODS: Fifty eyes of 38 patients with successful DSEK at a single tertiary referral center were followed up for at least 3 months. At the time of the study all patients were carefully examined to rule out any clinically detectable corneal edema. IOP was measured by Goldmann applanation tonometry (GAT), pneumotonometry (PT), and dynamic contour tonometry (DCT). IOP, OPA, and quality measurements were recorded. Central corneal thickness (CCT) was measured by ultrasonic pachymetry. RESULTS: Mean IOP was 15.9±4.9 mm Hg by GAT, 20.3±4.6 mm Hg by PT, and 19.8±4.4 mm Hg by DCT. Mean OPA was 2.53±1.24 mm Hg. OPA was correlated with GAT (r=0.357, P=0.011) and PT (r=0.316, P=0.026). The correlation of OPA and DCT approached significance (r=0.270, P=0.058). Mean CCT was 701±65 µm (range, 529 to 928 µm). OPA was not associated with CCT (r=0.238, P=0.096). CONCLUSIONS: In eyes with DSEK, our results showed that OPA was similar to that reported in normal eyes. Comparable with results in normal eyes, OPA was not associated with CCT but was associated with increasing IOP in DSEK eyes.

Surgical technique for excisional bleb revision using a rotational conjunctival flap for a large conjunctival defect.

Bleb dysesthesia is a common but under recognized late complication of trabeculectomy, sometimes requiring surgical revision if conservative measures fail. We describe in detail a surgical technique for closure of a large conjunctival defect following bleb excision for refractory dysesthesia. Two subconjunctival 5-fluorouracil injections were given to improve bleb function. Eight months post-operatively, the intraocular pressure is well controlled on two agents, and the patient has had resolution of dysesthesia.

Epidemiologic relationship between fuchs heterochromic iridocyclitis and the United States rubella vaccination program.

PURPOSE: To investigate an epidemiologic association between Fuchs heterochromic iridocyclitis (FHI) and the rubella vaccination program in the United States. DESIGN: Observational case series. METHODS: The percentages of patients with FHI, idiopathic chronic iridocyclitis, and idiopathic chronic granulomatous iridocyclitis at the University of Illinois were compared over time. Analysis of country of origin (United States vs foreign-born) was also performed. Findings were correlated with implementation of the rubella vaccination program in the United States in 1969. RESULTS: A total of 3,856 patients were seen between 1985 and 2005. Percentages of patients with FHI and idiopathic chronic granulomatous iridocyclitis born between 1919 and 1958 were similar (FHI 3.51% to 5.19%; idiopathic chronic granulomatous iridocyclitis 3.51% to 4.72%), with more variability in the idiopathic chronic iridocyclitis group (6.63% to 11.32%). A 64.8% reduction in FHI subjects was seen for those born the following decade (1959 to 1968). An additional 39.7% drop in FHI occurred in patients born between 1969 and 1978. Only one patient with FHI was born during the decade 1979 to 1988. The trend over time for FHI differed significantly from idiopathic chronic iridocyclitis (P = .0007) and idiopathic chronic granulomatous iridocyclitis (P = .0002), with no difference between the controls (P = .5437). The percentage of foreign-born patients with FHI increased after the institution of the rubella vaccination program (42% to 55%) compared with those born in previous decades (24% to 25%). This was not observed in the controls. CONCLUSION: FHI is less common in patients born since the introduction of the US rubella vaccination program, with a corresponding increase in percentage of foreign-born cases. This epidemiologic study supports a relationship between the rubella virus and FHI.

Diagnostic yield of the evaluation of isolated third nerve palsy in adults.

BACKGROUND: The neuroimaging evaluation of isolated third nerve palsy in adults remains controversial. We aim to define diagnostic yield for neuroimaging of third nerve palsy (TNP) by degree of internal and external dysfunction using previously published imaging guidelines. METHODS: All cases of TNP evaluated at a tertiary care center between 1990 and April 2004 were reviewed. Inclusion criteria were neurologically isolated TNP in adults with adequate documentation of the ocular examination, neuroimaging, and follow-up. Exclusion criteria were neurologically non-isolated TNP, TNP occurring in children, and TNP secondary to a known etiology; lack of adequate follow-up; and insufficient documentation of the ocular exam. Published imaging guidelines based on degree of external and internal dysfunction were applied to our cohort to determine compliance with and the diagnostic yield of neuroimaging recommendations. RESULTS: One hundred and eight cases were reviewed. Of the 91 excluded cases, there were 14 cases of aneurysm or subarachnoid hemorrhage. Of the 17 included cases, presumed ischemia (10), aneurysm (2), and ocular myasthenia (3) were the most common causes of isolated TNP. Neuroimaging was performed in 16 cases (94.1%). The neuroimaging strategy was concordant with neuroimaging recommendations in 7 cases (41.2% concordance). Failure to perform noninvasive angiography accounted for 7 cases (70.0%) of nonconcordance. The diagnostic yield of all neuroimaging studies performed was 68.8%; diagnostic yield in cases concordant with published neuroimaging recommendations was 100%. INTERPRETATION: The degree of external and internal dysfunction can direct the type of neuroimaging performed in TNP.

Tanning bed exposure increases the risk of malignant melanoma.

BACKGROUND: Epidemiologic studies have associated tanning bed exposure and cutaneous melanoma. The relationship between the extent of tanning bed exposure and the risk of melanoma has not been elucidated in detail. METHODS: Surveys assessing the extent of tanning bed exposure and the history of skin cancer, including malignant melanoma, were collected from academic dermatology clinic patients (n = 1518). Of these, 551 (36.3%) completed all components of the survey. The available medical records, including pathology reports (n = 501; 33%), were reviewed to confirm cases of skin cancer. Data on potential confounding factors, including indoor vs. outdoor occupation and leisure activities, Fitzpatrick skin type, history of blistering sunburn, use of sunscreen and sun protective clothing, history of phototherapy, and level of education, were assessed and compared. RESULTS: Of the patients surveyed, 487 (32.1%) reported tanning bed exposure. Women aged 45 years or younger accounted for about 60% of all tanning bed users. Seventy-nine cases of malignant melanoma were reported, 22 in women aged 45 years or younger. In the entire cohort, the "ever-use" of tanning beds was found to be a significant risk factor for the development of melanoma [P < 0.05; odds ratio (OR), 1.64; 95% confidence interval (95% CI), 1.01-2.67]. The risk was greater in women aged 45 years or younger (P < 0.05; OR, 3.22; 95% CI, 1.01-11.46). Patients with a history of melanoma were significantly more likely to report tanning bed sessions exceeding 20 min (P < 0.01; OR, 3.18; 95% CI, 1.48-6.82); this association was even stronger for women aged 45 years or younger (OR, 4.12; 95% CI, 1.41-12.02). LIMITATIONS: The study was subject to recall bias, included only patients at a midwestern academic practice, and had a relatively low response rate. CONCLUSION: Exposure to tanning beds increases the risk of malignant melanoma, especially in women aged 45 years or younger. These findings reinforce the hazards of tanning bed exposure.

Ocular disease in pregnancy.

PURPOSE OF REVIEW: Pregnancy may cause ocular changes, both physiologic and pathologic, and may be associated with the development of new disease or may alter the course of preexisting disease. This paper discusses these changes and reviews diabetic retinopathy, uveitis, preeclampsia, cortical blindness and central serous chorioretinopathy. RECENT FINDINGS: Recent reports have contributed to our understanding of the pathophysiology of diabetic retinopathy and cortical blindness associated with preeclampsia, the impact of pregnancy on the course of inflammatory eye disease, and the use of optical coherence tomography in following central serous chorioretinopathy in pregnant women. SUMMARY: This improved understanding of the pathophysiology of ocular disease in pregnancy and the impact of pregnancy on the course of preexisting ocular disease offers the opportunity for meaningful counseling of women who are pregnant or planning to become pregnant.

Righting wrong site surgery.

BACKGROUND: As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), wrong site surgery includes wrong side or siteof the body, wrong procedure, and wrong-patient surgeries. Although many health care organizations are implementing guidelines and procedures to decrease the occurrence of wrong site surgery, numerous barriers to their effectiveness have been identified. HUMAN FACTORS ENGINEERING (HFE) ANALYSIS: A human factors system analysis can be used to better understand how elements of a work system combine andinteract to contribute to breakdowns in the system. A case study of wrong site surgery in an outpatient setting illustrates how the different work systtem elements can contribute to the occurrence of a wrong site surgery. In analyzing the care process, it is particularly important to identify the transitions of care, which can be sources of patient safety problems when deficits in communication and information transfer occur (for example, miscommunication, information not transmitted on time, wrong information transmitted, misunderstanding of the information transmitted). RECOMMENDATIONS: After a wrong site surgery, conduct a root cause analysis that uses the work system model and includes a surgery care process analysis similar to the one described in the case study; collaborate with human factors engineers to learn how to apply the work system model; apply the work system model to process analysis; and optimize work systems.

Prevalence and correlates of depressive symptoms in a community sample of people suffering from heart failure.

OBJECTIVES: To examine the rates and correlates of depressive symptoms and syndromal depression in people with self-reported heart failure participating in a community study of people aged 70 and older. DESIGN: Cross-sectional. SETTING: Community-based epidemiological study of older people from the continental United States. PARTICIPANTS: Six thousand one hundred twenty-five older people participating in the longitudinal study of Assets and Health Dynamics. Participants had to be born in 1923 or earlier. MEASUREMENTS: The short-form Composite International Diagnostic Interview assessed syndromal depression, and a revised version of the Center for Epidemiologic Studies-Depression scale assessed depressive symptoms. Medical illness was based on self-report. The authors compared the rates of syndromal depression and individual depressive symptoms in people with self-reported heart failure (n = 199) with those in people with other heart conditions (n = 1,856) and with no heart conditions (n = 4,070). RESULTS: Eleven percent of those with heart failure met criteria for syndromal depression, compared with 4.8% of people with other heart conditions and 3.2% of those with no heart conditions. The association between heart failure and depression held even after controlling for disability, reported fatigue and breathlessness, and number of comorbid chronic illnesses. CONCLUSION: Community-living older people with self-reported heart failure were at approximately twice the risk for syndromal depression of the rest of the community. Although fatigue and functional disability were also related to depression in this sample, these variables did not account for the association between syndromal depression and self-reported heart failure.