The cascade of care for pregnant women with latent tuberculosis infection in a high-income country.

BACKGROUND: Pregnant women have an increased risk of developing active tuberculosis (TB). The Public Health Agency of Sweden recommends screening of active TB and latent tuberculosis infection (LTBI) among pregnant women from countries with high TB incidence at Maternal Health Care (MHC) clinics. In Östergötland County, Sweden, a screening program has been active since 2013. The aim of this study was to evaluate this screening program and the cascade of care for LTBI among pregnant women in Östergötland county. METHODS: Data were obtained from pregnant women screened for TB at MHC clinics and subsequently referred to the pulmonary medicine clinic or the clinic of infectious diseases in Östergötland County between 2013 and 2018. The Public Health Agency of Sweden's national database for active TB was used to analyse if any women developed active TB up to two years after the screening process. RESULTS: A total of 439 women were included. Nine cases of active TB were discovered during the screening process and two developed active TB afterward. 177 women were recommended LTBI treatment and variables significantly associated with a decreased likelihood of being recommended treatment were increasing age, time in Sweden, and parity. 137 women received and 112 (82%) completed treatment. 14 women discontinued treatment due to adverse effects. CONCLUSION: Screening of pregnant women from countries with high TB incidence at MHC clinics led to the discovery of several cases of active TB. The completion rate of LTBI treatment was high and few discontinued due to adverse effects.

Complications associated with secondary orbital implantations.

PURPOSE: To evaluate complications associated with secondary procedures for orbital implants. METHODS: A retrospective review was made of the records of patients who had undergone a secondary orbital implantation at a tertiary referral centre at St Erik Eye Hospital in Stockholm, Sweden, from 1998 up to and including the first half of 2009. Implant-related complications were noted as was demographic and surgical background data. The regional ethics committee in Stockholm gave its approval for this study. RESULTS: Seventy-one patients had received a secondary orbital implant at the eye hospital. Implant-related complications were noted in 24 patients (34%), and 20 patients required reoperation/s (28%). There were five types of complications: migration of the implant (13%), insufficient orbital volume (10%), exposure/extrusion/infection (8%), mechanical obstruction (1%) and socket oedema (1%). Analyses of sizes and types of implants, wrapping and surgical techniques did not reveal any specific factor that resulted in an increased number of complications. However, there was an indication that aluminium oxide might be associated with fewer complications (2/11 = 18%). CONCLUSION: Our results show that secondary orbital implantations have high complication rates and that further surgery is needed in more than a quarter of cases. It is important to consider these facts when planning to insert secondary implants and to provide patients with accurate information about the procedure and possible outcomes.

Increased levels of inflammatory immune mediators in vitreous from pseudophakic eyes.

PURPOSE: To determine if pseudophakic eyes have an increased and sustained level of inflammatory immune mediators in the vitreous compared to phakic eyes. METHODS: Vitreous fluid samples were obtained from 73 patients undergoing elective pars plana vitrectomy (PPV) as a result of a macular hole, epiretinal membrane, vitreous macular traction, or vitreous floaters. Forty eyes were pseudophakic and had previously undergone uncomplicated cataract surgery, ranging from a few months to several years prior to PPV. The vitreous samples were analyzed for 29 different inflammatory immune mediators using multiplex bead immunoassays. RESULTS: A total of 14 cytokines (eotaxin, interferon-γ-induced protein-10 [IP-10], monocyte chemotactic protein-1 [MCP-1], macrophage derived chemokine [MDC], macrophage inflammatory protein [MIP]-1α, MIP-1ß, thymus activation regulated chemokine [TARC], IL-12p40, IL-15, IL-16, IL-7, VEGF, IL-6, and IL-8) were detected in the vitreous of both study groups. Using multiple linear regression analysis, pseudophakia was significantly correlated with higher levels of vitreous immune mediators compared to phakia. Elevated vitreous levels were estimated to decrease over time for IL-6, IL-8, IL-15, IL-16, and VEGF, though they remained elevated for many months and even years compared to the levels detected in phakic eyes. CONCLUSIONS: This is the first study to demonstrate that cataract surgery and pseudophakia can induce increased vitreous levels of a substantial range of inflammatory immune mediators. The elevated levels seem to be maintained for a long period of time. These increased levels of cytokines may be involved in inflammatory processes leading to several complications to cataract surgery, both early and late.

Five-year incidence of Nd:YAG laser capsulotomy and association with in vitro proliferation of lens epithelial cells from individual specimens: a case control study.

BACKGROUND: The aims of this study were to determine the 5-year incidence of posterior capsule opacification (PCO) requiring Nd:YAG laser capsulotomy in a representative mixed cohort of cataract patients, to determine risk factors for PCO and to investigate possible association with growth of human lens epithelial cells (HLEC) in vitro. METHODS: Pieces of the anterior lens capsule and adhering HLEC were obtained at cataract surgery and cultured individually. After one and two weeks respectively, cultured cells were stained with carboxy-fluorescein diacetate succinimidyl ester (CFDA SE), after which image processing software was used to determine the area of the confluent cell layer. The 5-year incidence of Nd:YAG laser capsulotomy in this cohort was determined through medical records and by mail or telephone interviews. For statistic analyses Mann-Whitney U-test, Fisher's exact test and binary logistic regression were used. RESULTS: Data on treatment/no treatment for PCO was obtained from 270 patients with a median follow-up time of 57 months (range 50-64 months). The three-year cumulative incidence of PCO was 5.2% and the cumulative 5-year incidence was 11.9%. Patients who had undergone Nd:YAG laser capsulotomy were significantly younger (median 71 years) than patients who did not receive treatment for PCO (median 75 years, p = 0.022). Logistic regression demonstrated that apart from younger age, follow-up time and type of intraocular lens (IOL) were associated with risk of PCO, with hydrophilic 1-piece IOLs conferring a higher risk than hydrophobic acrylic 1-piece or 3-piece IOLs (adjusted OR = 9.4, 95% CI 2.5-35.7, p = 0.001). Of the 270 patients from whom information could be retrieved regarding PCO treatment, in vitro cell culture could be established and quantified from 185 patients. No significant difference in cell growth in vitro was shown between patients subsequently requiring/not requiring Nd:YAG laser capsulotomy. CONCLUSIONS: The cumulative 5-year incidence of 11.9% is comparable or slightly higher than reported in other recent studies. The type of IOL was the most important risk factor for PCO in this study, whereas intrinsic proliferative capacity of the individual's lens epithelial cells seems to be less important for subsequent PCO development.

In vitro growth of lens epithelial cells from cataract patients - association with possible risk factors for posterior capsule opacification.

AIM: Inter-individual differences in intrinsic proliferative capacity of lens epithelial cells may have importance for the risk of developing posterior capsule opacification (PCO) after cataract surgery. The purpose of the present study was to determine growth of human lens epithelial cells (HLEC) in culture and investigate possible associations with clinical characteristics of the donors, such as age, sex, pseudoexfoliation, uveitis and diabetes. METHODS: Pieces of lens capsule and adhering lens epithelial cells were obtained through capsulorhexis at cataract surgery. Specimens were cultured in a humidified CO2-incubator using standard culture medium and 5% fetal calf serum for two weeks after which cultured cells were stained with carboxy-fluorescein diacetate succinimidyl ester. Image processing software was used to determine the area of the confluent epithelial cell layer in relation to the size of the original capsule specimen. RESULTS: The increase in area of confluent HLEC showed a negative correlation with diabetes at the first week after surgery. Lower age and female sex showed border-line significant associations with a higher rate of cell proliferation. The presence of pseudoexfoliation in vivo did not significantly affect cell growth in culture postoperatively. Nor did installation of xylocain in the anterior chamber during surgery. CONCLUSION: Diabetes is associated with lower rate of proliferation of lens epithelial cells in culture. The lack of strong correlations between in vitro growth and known risk factors for PCO in the donors suggest that other factors than the proliferative capacity of the cells per se are important for PCO formation.

Surgical repositioning of intraocular lenses after late dislocation: complications, effect on intraocular pressure, and visual outcomes.

PURPOSE: To study outcomes after surgery for late intraocular lens (IOL) dislocation and, more specifically, to evaluate different surgical techniques to find predictors of worse visual outcomes, describe postoperative complications, and analyze the effect on intraocular pressure (IOP). SETTING: Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden. DESIGN: Prospective observational cohort study. METHODS: Medical records from cataract surgery, IOL repositioning, and follow-up examinations were reviewed. RESULTS: Ninety-one eyes with in-the-bag (80) or out-of-the-bag (11) late IOL dislocation were consecutively included. In 94% of eyes, the IOLs were repositioned using scleral sutures; 76% of cases were operated on with a posterior approach, including pars plana vitrectomy. The median follow-up was 17 months. Pseudoexfoliation was detected in 57% of eyes. A significant decrease in IOP (mean 3.0 mm Hg) from preoperative values (P=.028) was seen in glaucoma patients. Thirteen eyes had additional surgical procedures. Three cases of retinal detachment occurred. Of the eyes, 59% obtained a Snellen corrected distance visual acuity (CDVA) of 0.5 or more at follow-up; 23% of eyes had worse CDVA during the follow-up than preoperatively. CONCLUSIONS: Repositioning surgery for late IOL dislocation with a posterior pars plana approach using scleral suturing of the preexisting IOL appears to be a safe and effective method for restoring visual acuity. Postoperative complications were comparable to previous findings in this field. Patients with glaucoma may have improved IOP regulation.

Outcome of capsulotomy in patients with low vision and posterior capsule opacification.

PURPOSE: To investigate the functional outcome, as defined using the Catquest questionnaire, for patients with posterior capsule opacification (PCO) and low corrected distance visual acuity (CDVA), after capsulotomy. METHODS: Thirty-one patients with PCO and visual acuity ≥ 0.6 (log MAR, ≤ 0.25 decimal notation) in the PCO eye were examined before and 1 month after capsulotomy. An ophthalmic examination, procuring of a digital image of the posterior lens capsule and completion of Catquest were carried out. RESULTS: Mean CDVA (p < 0.001), disabilities in daily life (p = 0.004), activity (p = 0.012), symptoms of glare (p = 0.003) and satisfaction with vision (p < 0.001) all improved after capsulotomy. Sixty-five per cent of patients had good or very good benefit and 23% questionable or no benefit. The group with moderate benefit was only 6%. Compared with patients with PCO and better visual acuity, the number of patients with good benefit was greater than the number with moderate benefit. CONCLUSIONS: Most patients with PCO and low CDVA reported improved visual function in daily life as defined using Catquest, after capsulotomy. The group with moderate benefit was small, indicating that the improvement was either substantial or negligible.

Late dislocation of in-the-bag and out-of-the bag intraocular lenses: ocular and surgical characteristics and time to lens repositioning.

PURPOSE: To characterize patients with late intraocular lens (IOL) dislocation to evaluate possible risk factors, determine the time between cataract surgery and IOL repositioning, describe the surgical management, and estimate the incidence. SETTING: Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden. DESIGN: Case series. METHODS: Medical records from the cataract surgery and IOL repositioning were reviewed. RESULTS: The study enrolled 84 eyes, 63 with in-the-bag IOL dislocation and 21 with out-of-the-bag IOL dislocation. The prevalence of pseudoexfoliation (PXF) was 60% and of glaucoma, 36%. A high proportion of eyes with IOL dislocation (37%) had zonular dehiscence at cataract surgery. The median time from cataract surgery to IOL repositioning surgery was significantly shorter in eyes with out-of-the-bag IOL dislocation (3.2 years) than in eyes with in-the-bag IOL dislocation (6.7 years) (P = .029). The interval was also significantly shorter in eyes with zonular dehiscence. Using data from the National Cataract Register, the calculated incidence of IOL repositioning surgery per pseudophakic individuals in western Sweden was 0.050%. CONCLUSIONS: The possible major predisposing factors for late IOL dislocation were PXF, glaucoma, and cataract surgery complicated by zonular dehiscence. Primary placement of the IOL in the ciliary sulcus was associated with earlier IOL dislocation. Intraocular lens repositioning surgery using a posterior or anterior approach was successful in many cases. FINANCIAL

Myofibroblasts in the normal conjunctival surface.

PURPOSE: To investigate the occurrence of myofibroblasts (MFBs) in the normal conjunctival surface and to evaluate any anatomical and time-related variations. METHODS: MFBs were screened among healthy individuals (35 eyes) by collecting impression cytology (IC) samples from the bulbar conjunctiva. A cohort of volunteers (12 eyes) was followed for 1 year by taking two to five imprints every month. MFBs were identified by immunohistochemical localization of the MFB marker alpha-smooth-muscle actin (alpha-SMA). RESULTS: Using a filter imprint technique, MFBs were found consistently in 94% of samples from the conjunctival surface of participating individuals. The overall MFB levels, expressed as percentage of all cells on the filter, were highest in March-May [mean 4.1%, standard deviation (SD) +/- 1.5] and lowest in December-February (mean 1.2%, SD +/- 0.5). The difference was statistically significant [p < 0.0005, Friedman test, one-way repeated measures analysis of variance (anova)]. Moreover, there was a clear divergence of MFB density between the nasal, temporal, superior and inferior bulbar conjunctiva (mean 1.7%, 1.9%, 22% and 9.7%, respectively). CONCLUSION: MFBs, known as a cellular constituent of granulation tissue in wound healing, occur in the normal conjunctival surface, which is a novel finding. Our results also show that MFB level follows a seasonal variation pattern in a temperate climate, increasing in April-September and decreasing in October-March. This variation might reflect a degree of a transient or ongoing state of tissue repair after conjunctival trauma or stress caused by exposure to environmental factors.

Increased anterior chamber penetration of topical levofloxacin 0.5% after pulsed dosing in cataract patients.

PURPOSE: This study aimed to investigate the rise in aqueous humour (AH) levels of levofloxacin after a specific perioperative pulsed topical drop regimen. METHODS: Thirty patients undergoing phacoemulsification surgery were administered two preoperative drops of levofloxacin 0.5%, 30 mins apart, and three pulsed drops postoperatively, 5 mins apart. Aqueous humour levels of levofloxacin were measured at the start of surgery and from 5 mins to 90 mins after the last postoperative drop. Samples from individual patients were collected at the time of surgery and at one additional sampling interval by aqueous tap, and analysed using a high-performance liquid chromatography assay. RESULTS: Aqueous humour levels of levofloxacin continued to rise gradually, reaching a mean peak level (C(max)) of 4.4 microg/ml (+/- 2.5) at 60 mins after the last postoperative drop was administered. This level exceeded the minimum inhibitory concentration of common ocular pathogens at least fourfold. At 90 mins after the last drop, mean AH levels remained > 3 microg/ml. CONCLUSIONS: This is the first study to measure AH levels of levofloxacin after postoperative pulsed dosing in humans. Higher AH levels were found than in previously reported studies in which only preoperative drops were given and levels were measured at the time of surgery. Levels of levofloxacin continued to rise for 60 mins after administration of the last postoperative drop, demonstrating that delivery and maintenance of effective antibiotic levels may be achievable with alternative dosing schedules.

Posterior capsule opacification: comparisons between morphology, visual acuity and self-assessed visual function.

PURPOSE: To investigate whether posterior capsule opacification (PCO) morphology, visual acuity (VA) and self-assessed visual function correlate, and to compare perceived visual disabilities with those of cataract patients with corresponding VA. METHODS: Twenty-one patients with PCO were examined before capsulotomy. In adjunct to the ophthalmological examination, the patients completed a Catquest questionnaire and a digitized retroillumation image was acquired. The images were analysed with the Evaluation of Posterior Capsule Opacification (EPCO) program. Data for visual function were compared with data from the National Swedish Cataract Register (NCR). RESULTS: The epco values were correlated with VA in the PCO eyes: the higher the epco score, the lower the VA. There were also correlations between the epco scores, satisfaction with vision, and perceived disabilities in daily life. Symptoms of glare were not significantly correlated with epco scores or with VA. Visual acuity in PCO eyes was better correlated with perceived disabilities and satisfaction with vision than VA in eyes with cataract. CONCLUSIONS: There was a significant correlation between epco scores and VA and between epco scores and Catquest. Consequently, the morphological method was related to the self-assessed visual function. Patients with PCO seemed to have more disturbed visual function, as defined by Catquest, than cataract patients with the same VA.

Three-year follow-up of posterior capsule opacification with two different silicone intraocular lenses.

PURPOSE: To compare posterior capsule opacification (PCO) after cataract surgery with implantation of two silicone intraocular lenses (IOLs) with different designs. METHODS: We carried out a prospective, clinical study of 116 patients randomized to standardized phacoemulsification with implantation of CeeOn Edge (n = 57) or SI40NB (n = 59) IOLs. The follow-up period was 3 years. To evaluate PCO morphologically, digital images were obtained and analysed using evaluation of posterior capsule opacification computer software (epco). The neodymium:YAG (Nd:YAG) capsulotomy rate was recorded. RESULTS: At 2 and 3 years, the eyes with SI40NB IOLs had significantly more PCO than those with the CeeOn Edge IOLs (p = 0.00014 and p = 0.002). Nine Nd:YAG capsulotomies were performed in the SI40NB group and none in the CeeOn Edge group. This difference was statistically significant (p = 0.003). In some patients a regression of PCO was noticed and confirmed using epco. Statistically less PCO was noted when the capsulorhexis rim was placed so that it covered all 360 degrees of the optic of the IOL. CONCLUSIONS: A clinically and statistically significant difference in PCO development between CeeOn Edge and SI40NB IOLs at 2 and 3 years postoperatively was found. These findings support earlier studies indicating that a sharp edge of the optic is a more important factor in IOL design than IOL material in the prevention of PCO.

Self-assessed visual function for patients with posterior capsule opacification before and after capsulotomy.

PURPOSE: To describe the functional outcome, as defined using the Catquest questionnaire, for patients with posterior capsule opacification (PCO) after capsulotomy. METHODS: A total of 47 patients with PCO were examined before and 1 month after capsulotomy. In addition to the ophthalmic examination, Catquest was completed and a digital image of the posterior lens capsule acquired. RESULTS: Capsulotomy resulted in a good level of benefit, as defined using Catquest, for 77% of the patients. No subgroup of patients who derived an exceedingly good or poor level of benefit was identified. Disabilities in daily life, satisfaction with vision and symptoms of glare improved from treatment (p < 0.001, p < 0.001 and p = 0.002, respectively). The results were comparable with the benefits of cataract surgery. CONCLUSIONS: Self-assessed visual function as defined using Catquest improved after capsulotomy for the vast majority of patients with PCO. No group of patients with exceptionally good or poor levels of benefit could be identified with certainty. However, the majority of those with a poor outcome were elderly individuals with ocular comorbidity. The overall functional results from treatment of PCO were very similar to those achieved after cataract surgery.