Comparison of 5% Sulfur Hexafluoride Versus 100% Air Tamponade in Descemet Membrane Endothelial Keratoplasty

 5% Sulfur Hexafluoride,100% Air Tamponade , Descemet Membrane Endothelial Keratoplasty

2017 Jul 24. doi: 10.1097/ICO.0000000000001299. [Epub ahead of print]

Comparison of 5% Sulfur Hexafluoride Versus 100% Air Tamponade in Descemet Membrane Endothelial Keratoplasty.

Abstract

PURPOSE:

To compare the rebubbling rate and clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) with 5% sulfur hexafluoride (SF6) gas versus 100% air as a tamponade for graft attachment.

METHODS:

Retrospective, comparative, interventional case series including 368 consecutive pseudophakic eyes with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy that underwent DMEK in a tertiary referral center between October 2010 and August 2015 using either air (group 1, 191 eyes) or 5% SF6 (group 2, 177 eyes) as a tamponade. The rebubbling rate, complications, best-corrected distance visual acuity (BCVA), manifest refraction, and endothelial cell density were analyzed before and at 1 week, 1, 3, 6, 12, 24, and 36 months after surgery.

RESULTS:

The rebubbling rate was 20.4% (39/191, group 1) versus 6.8% (12/177, group 2; P < 0.001). Complications included cystoid macular edema (n = 5, group 1, and n = 10, group 2; P = 0.14) and 1 case of presumed allograft rejection (n = 1, group 2). The follow-up period was 12 ± 8 months for group 1 and 6 ± 4 months for group 2. BCVA (logarithm of the minimum angle of resolution) had improved after 12 months from 1.43 ± 0.63 to 0.18 ± 0.26 (group 1, P < 0.001) and from 1.8 ± 0.63 to 0.18 ± 0.17 (group 2, P < 0.001). The percentage of eyes with BCVA ≥0.2 logarithm of the minimum angle of resolution at 12 months was 70.9% (90/127, group 1) and 78.4% (40/51, group 2; P = 0.3). Endothelial cell loss at 12 months after DMEK was 44 ± 18% (group 1) versus 33 ± 15% (group 2, P = 0.07).

CONCLUSIONS:

The use of a tamponade with 5% SF6 yielded a significantly lower incidence of graft detachment requiring surgical reintervention with no detrimental effect on graft endothelial cells. Thus, routine use of 5% SF6 for a graft tamponade in DMEK is recommended.

 5% Sulfur Hexafluoride,100% Air Tamponade , Descemet Membrane Endothelial Keratoplasty

PMID:
28742620

The percentage of eyes with BCVA ≥0.2 logarithm of the minimum angle of resolution at 12 months was 70.9% (90/127, group 1) and 78.4% (40/51, group 2; P = 0.3). Endothelial cell loss at 12 months after DMEK was 44 ± 18% (group 1) versus 33 ± 15% (group 2, P = 0.07).

CONCLUSIONS:

The use of a tamponade with 5% SF6 yielded a significantly lower incidence of graft detachment requiring surgical reintervention with no detrimental effect on graft endothelial cells. Thus, routine use of 5% SF6 for a graft tamponade in DMEK is recommended.

 5% Sulfur Hexafluoride,100% Air Tamponade , Descemet Membrane Endothelial Keratoplasty
 5% Sulfur Hexafluoride,100% Air Tamponade , Descemet Membrane Endothelial Keratoplasty
DOI:
10.1097/ICO.0000000000001299

Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football

Clinicopathological Evaluation, Traumatic Encephalopathy , Football
2017 Jul 25;318(4):360-370. doi: 10.1001/jama.2017.8334.

Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football.

Abstract

IMPORTANCE:

Players of American football may be at increased risk of long-term neurological conditions, particularly chronic traumatic encephalopathy (CTE).

OBJECTIVE:

To determine the neuropathological and clinical features of deceased football players with CTE.

DESIGN, SETTING, AND PARTICIPANTS:

Case series of 202 football players whose brains were donated for research. Neuropathological evaluations and retrospective telephone clinical assessments (including head trauma history) with informants were performed blinded. Online questionnaires ascertained athletic and military history.

EXPOSURES:

Participation in American football at any level of play.

MAIN OUTCOMES AND MEASURES:

Neuropathological diagnoses of neurodegenerative diseases, including CTE, based on defined diagnostic criteria; CTE neuropathological severity (stages I to IV or dichotomized into mild [stages I and II] and severe [stages III and IV]); informant-reported athletic history and, for players who died in 2014 or later, clinical presentation, including behavior, mood, and cognitive symptoms and dementia.

RESULTS:

Among 202 deceased former football players (median age at death, 66 years [interquartile range, 47-76 years]), CTE was neuropathologically diagnosed in 177 players (87%; median age at death, 67 years [interquartile range, 52-77 years]; mean years of football participation, 15.1 [SD, 5.2]), including 0 of 2 pre-high school, 3 of 14 high school (21%), 48 of 53 college (91%), 9 of 14 semiprofessional (64%), 7 of 8 Canadian Football League (88%), and 110 of 111 National Football League (99%) players. Neuropathological severity of CTE was distributed across the highest level of play, with all 3 former high school players having mild pathology and the majority of former college (27 [56%]), semiprofessional (5 [56%]), and professional (101 [86%]) players having severe pathology. Among 27 participants with mild CTE pathology, 26 (96%) had behavioral or mood symptoms or both, 23 (85%) had cognitive symptoms, and 9 (33%) had signs of dementia. Among 84 participants with severe CTE pathology, 75 (89%) had behavioral or mood symptoms or both, 80 (95%) had cognitive symptoms, and 71 (85%) had signs of dementia.

CONCLUSIONS AND RELEVANCE:

In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football.

PMID:
28742910

Clinicopathological Evaluation, Traumatic Encephalopathy , Football

DOI:
10.1001/jama.2017.8334

Corticosteroid-Related Adverse Events Systematically Increase with Corticosteroid Dose in Noninfectious Intermediate, Posterior, or Panuveitis: Post Hoc Analyses from the VISUAL-1 and VISUAL-2 Trials

Corticosteroid,Adverse Events,Dose,Noninfectious, Intermediate, Posterior, Panuveitis,VISUAL-1 , VISUAL-2 Trials

2017 Jul 6. pii: S0161-6420(17)30359-7. doi: 10.1016/j.ophtha.2017.06.017. [Epub ahead of print]

Corticosteroid-Related Adverse Events Systematically Increase with Corticosteroid Dose in Noninfectious Intermediate, Posterior, or Panuveitis: Post Hoc Analyses from the VISUAL-1 and VISUAL-2 Trials.

Abstract

PURPOSE:

Chronic use of corticosteroids for the treatment of uveitis has been linked with drug-associated toxicity and adverse events (AEs). This study examines the association between corticosteroid dosage and incidence rates of corticosteroid-related AEs.

DESIGN:

A post hoc analysis of the VISUAL-1 and VISUAL-2 placebo-controlled clinical trials.

PARTICIPANTS:

The clinical trials consisted of adults with active (VISUAL-1) and inactive (VISUAL-2) noninfectious intermediate, posterior, and panuveitis. Patients were randomized to receive adalimumab or placebo and underwent a protocol-defined mandatory taper to discontinue their oral corticosteroids.

METHODS:

Adverse event data were collected at each visit and included an assessment of the corticosteroid relationship by the investigator. A longitudinal Poisson regression model was estimated controlling for time-dependent corticosteroid dose, age, sex, prior oral corticosteroid dose, prior topical corticosteroid use, and concomitant immunosuppressive drug use. Only patients randomized to placebo were considered.

MAIN OUTCOME MEASURES:

The primary outcome measure was the frequency of AEs.

RESULTS:

The incidence rates of corticosteroid-related AEs among placebo patients during the prednisone treatment period in VISUAL-1 was statistically higher than after discontinuation (454.2 per 100 patient-years [PY] vs. 36.1 per 100 PY, incident rate ratio = 12.6, P < 0.001). Incidence rate ratios among VISUAL-2 patients were similarly high (317.5 per 100 PY vs. 41.1 per 100 PY, incident rate ratio = 7.7, P < 0.001). Based on the Poisson multivariate longitudinal Generalized Estimating Equation (GEE) model, each 10 mg increase in prednisone dose is associated with a 1.5- and 2.6-fold increase (P < 0.001 and P < 0.001) in the rate of corticosteroid-related AEs in VISUAL-1 and VISUAL-2, respectively. This implies in turn that a patient with active uveitis taking 60 mg/day of prednisone will experience, on average, an additional 10.1 (95% confidence interval (CI), 6.3-14.5; P < 0.001) corticosteroid-related AEs per year compared with a patient taking 10 mg/day, whereas a patient with inactive uveitis taking 35 mg/day of prednisone will experience, on average, an additional 23.5 (95% CI, 7.6-52.7; P = 0.05) corticosteroid-related AEs per year compared with a patient taking 10 mg/day.

CONCLUSIONS:

Evidence from VISUAL-1 and VISUAL-2 suggests that the incidence rates of corticosteroid-related AEs increase systematically with corticosteroid dose.

PMID:
28689898

Corticosteroid,Adverse Events,Dose,Noninfectious, Intermediate, Posterior,Panuveitis,VISUAL-1 , VISUAL-2 Trials

DOI:
10.1016/j.ophtha.2017.06.017

Disinfection of Tonometers

Disinfection ,Tonometers

2017 Jul 11. pii: S0161-6420(17)31677-9. doi: 10.1016/j.ophtha.2017.05.033. [Epub ahead of print]

Disinfection of Tonometers: A Report by the American Academy of Ophthalmology.

Abstract

OBJECTIVE:

To examine the efficacy of various disinfection methods for reusable tonometer prisms in eye care and to highlight how disinfectants can damage tonometer tips and cause subsequent patient harm.

METHODS:

Literature searches were conducted last in October 2016 in the PubMed and the Cochrane Library databases for original research investigations. Reviews, non-English language articles, nonophthalmology articles, surveys, and case reports were excluded.

RESULTS:

The searches initially yielded 64 unique citations. After exclusion criteria were applied, 10 laboratory studies remained for this review. Nine of the 10 studies used tonometer prisms and 1 used steel discs. The infectious agents covered in this assessment include adenovirus 8 and 19, herpes simplex virus (HSV) 1 and 2, human immunodeficiency virus 1, hepatitis C virus, enterovirus 70, and variant Creutzfeldt-Jakob disease. All 4 studies of adenovirus 8 concluded that after sodium hypochlorite (dilute bleach) disinfection, the virus was undetectable, but only 2 of the 4 studies found that 70% isopropyl alcohol (e.g., alcohol wipes or soaks) eradicated all viable virus. All 3 HSV studies concluded that both sodium hypochlorite and 70% isopropyl alcohol eliminated HSV. Ethanol, 70% isopropyl alcohol, dilute bleach, and mechanical cleaning all lack the ability to remove cellular debris completely, which is necessary to prevent prion transmission. Therefore, single-use tonometer tips or disposable tonometer covers should be considered when treating patients with suspected prion disease. Damage to tonometer prisms can be caused by sodium hypochlorite, 70% isopropyl alcohol, 3% hydrogen peroxide, ethyl alcohol, water immersion, ultraviolet light, and heat exposure. Disinfectants can cause tonometer tips to swell and crack by dissolving the glue that holds the hollow tip together. The tonometer tip cracks can irritate the cornea, harbor microbes, or allow disinfectants to enter the interior of the tonometer tip.

CONCLUSIONS:

Sodium hypochlorite (dilute bleach) offers effective disinfection against adenovirus and HSV, the viruses commonly associated with nosocomial outbreaks in eye care. Tonometer prisms should be examined regularly for signs of damage.

Disinfection ,Tonometers

Diabetic macular edema with and without subfoveal neuroretinal detachment

Diabetic, macular edema,subfovea neuroretinal detachment

2017 Jul 4. pii: S0002-9394(17)30280-5. doi: 10.1016/j.ajo.2017.06.026. [Epub ahead of print]

Diabetic macular edema with and without subfoveal neuroretinal detachment: two different morphological and functional entities.

Abstract

PURPOSE:

To assess specific morphologic and functional characteristics in eyes with diabetic macular edema (DME) with subfoveal neuroretinal detachment (SND+) vs DME without SND (SND-).

DESIGN:

Cross-sectional, prospective, comparative case series.

METHODS:

Seventy two patients (72 eyes: 22 eyes SND+ and 50 eyes SND-) with treatment-naïve, center-involving DME were evaluated. Data gathering included fundus color photographs, fluorescein angiography, spectral-domain optical coherence tomography (SD-OCT), best corrected visual acuity (BCVA), and microperimetry. The following parameters were evaluated with SD-OCT: central macular thickness (CMT, including SND); central retinal thickness (CRT, excluding SND); choroidal thickness (CT); nasal and temporal retinal thickness (RT) at 500 μm and 1500 μm from the fovea; the number of hyper-reflective retinal spots (HRS) in the central 3000 μm; and the presence of SND and integrity of the external limiting membrane (ELM). Retinal sensitivity (RS) was evaluated within 4° and 12° of the fovea. Correlation among CT, RS, and HRS in patients with and without SND was determined.

RESULTS:

CMT (P=0.032), temporal RT at 1500 μm (P=0.03), mean CT (P=0.009) and mean number of HRS (P=0.0001) were all higher in SND+ vs SND- eyes. CRT, BCVA, HbA1c, and prevalence of systemic arterial hypertension were not different between the two groups. RS within 4° (P=0.002) and 12° (P=0.015) was lower in SND+ vs SND- eyes. SND correlated significantly with disruption of the ELM (54.55% vs 24%, P=0.01) and lower RS. A direct correlation was found between the number of HRS, presence of SND, CT, and RS within 12° in SND- eyes, and an inverse correlation was found between CT and RS within 12° in SND+ eyes.

CONCLUSIONS:

This data may improve characterization of DME in eyes with SND. DME with SND correlates with greater CT, more HRS, disruption of the ELM and significant macular functional impairment (RS decrease) vs SND-.

KEYWORDS:

OCT; choroidal thickness; diabetic macular edema; external limiting membrane; fixation; hyperreflective spots; microperimetry; neuroretinal detachment; retinal sensitivity

Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin

Risk, Intraocular Bleeding, Anticoagulant, Warfarin

2017 Jul 6. doi: 10.1001/jamaophthalmol.2017.2199. [Epub ahead of print]

Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin: A Systematic Review and Meta-analysis.

Abstract

IMPORTANCE:

It is unclear if the risk of intraocular bleeding with novel oral anticoagulants differs compared with warfarin.

OBJECTIVE:

To characterize the risk of intraocular bleeding with novel oral anticoagulants compared with warfarin.

DATA SOURCES:

A systematic review and meta-analysis was undertaken in an academic medical setting. MEDLINE and ClinicalTrials.gov were searched for randomized clinical trials published up until August 2016. This search was supplemented by manual bibliography searches of identified trials and other review articles.

STUDY SELECTION:

Studies were eligible for inclusion if they were phase 3 randomized clinical trials, enrolled patients with atrial fibrillation or venous thromboembolism, compared a novel oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) with warfarin, and recorded event data on intraocular bleeding. Data on intraocular bleeding were pooled using inverse-variance, weighted, fixed-effects meta-analysis.

DATA EXTRACTION AND SYNTHESIS:

The PRISMA guidelines were used for abstracting data and assessing quality. Independent extraction was performed by 2 investigators.

MAIN OUTCOMES AND MEASURES:

Intraocular bleeding events and associated risk ratio for novel oral anticoagulants compared with warfarin.

RESULTS:

Twelve trials investigating 102 627 patients were included. Randomization to novel oral anticoagulants was associated with a 22% relative reduction in intraocular bleeding compared with warfarin (risk ratio, 0.78; 95% CI, 0.61-0.99). There was no significant heterogeneity observed (I2 = 4.8%, P = .40). Comparably lower risks of intraocular bleeding with novel oral anticoagulants were seen in subgroup analyses, with no significant difference according to the indication for anticoagulation (P for heterogeneity = .49) or the novel oral anticoagulant type (P for heterogeneity = .15). Summary estimates did not differ materially when random-effects meta-analytic techniques were used.

CONCLUSIONS AND RELEVANCE:

These results suggest that novel oral anticoagulants reduce the risk of intraocular bleeding by approximately one-fifth compared with warfarin. Similar benefits were seen in both patients with atrial fibrillation and venous thromboembolism. Our data have particular relevance for patients at higher risk of spontaneous retinal and subretinal bleeding. These findings may also have important implications in the perioperative period, in which the use of novel oral anticoagulants may be superior. Future studies are required to better characterize the optimal management of patients with both ophthalmic disease and cardiovascular comorbidities requiring anticoagulation.

PMID:
28687831
DOI:
10.1001/jamaophthalmol.2017.2199

Risk Factors for Secondary Glaucoma in Herpetic Anterior Uveitis

2017 Jun 27. pii: S0002-9394(17)30258-1. doi: 10.1016/j.ajo.2017.06.013. [Epub ahead of print]

Risk Factors for Secondary Glaucoma in Herpetic Anterior Uveitis.

Abstract

PURPOSE:

To determine the incidence of elevated intraocular pressure (IOP) and secondary glaucoma in herpetic anterior uveitis (AU), due to either herpes simplex or varicella zoster virus, by using the Standardization of Uveitis Nomenclature (SUN) criteria, and to identify risk factors for the development of glaucoma.

DESIGN:

Retrospective, observational cohort study.

METHODS:

Patients with herpetic AU presenting themselves between 2001 and 2013 at the ophthalmology department of the University Medical Center Groningen were included. Main outcome measures were the incidence of elevated IOP and glaucoma and risk factors for the development of glaucoma.

RESULTS:

Seventy-three herpetic AU patients were included. Ocular complications most commonly seen during follow-up for uveitis were elevated IOP (75%), keratitis (59%), dry eyes (34%), posterior synechiae (34%), cataract (32%), and glaucoma (15%). Glaucoma patients, in comparison to non-glaucoma patients, had a higher number of IOP peaks during their follow-up for uveitis (p<0.001). The majority of patients with elevated IOP (91%) had this already at the start of the uveitis. Nineteen percent of the patients needed glaucoma surgery.

CONCLUSIONS:

Using the SUN criteria, our study confirmed that elevated IOP and secondary glaucoma are major complications in herpetic AU. If an elevated IOP occurred, it was usually already present at the start of a uveitis episode. A risk factor for the development of glaucoma was the number of endured IOP peaks. Future studies are needed to evaluate whether early and prolonged use of antiviral and IOP-lowering medication may prevent glaucoma.

Risk factors, glaucoma, herpetic, uveitis

PMID:
28666730
DOI:
10.1016/j.ajo.2017.06.013

Cataract Study II: reducing complications by preoperative risk stratification and case allocation

Cataract , complications, teaching hospital
2017 Jun 27. pii: S0002-9394(17)30259-3. doi: 10.1016/j.ajo.2017.06.014. [Epub ahead of print]

The Auckland Cataract Study II: reducing complications by preoperative risk stratification and case allocation in a teaching hospital.

Abstract

PURPOSE:

To assess the effect of preoperative risk stratification for phacoemulsification surgery on intraoperative complications in a teaching hospital. Design; Prospective cohort study.

METHODS:

Prospective assessment of consecutive phacoemulsification cases (N=500) enabled calculation of a risk score (M-score of 0-8) using a risk stratification system (Muhtaseb et al). M-scores of >3 were allocated to senior surgeons. All surgeries were performed in a public teaching hospital setting, Auckland, New Zealand, in early 2016. Post-operatively data were reviewed for complications and corrected distance visual acuity (CDVA). Results were compared to a prospective study (N=500, Phase 1) performed prior to formal introduction of risk stratification.

RESULTS:

Intraoperative complications increased with increasing M-scores (P=0.044). Median M-score for complicated cases was higher (P=0.022). Odds ratio for a complication increased 1.269 per unit increase in M-score (95% CI 1.007-1.599, P=0.043). Overall rate of any intraoperative complication was 5.0%. Intraoperative complication rates decreased from 8.4% to 5.0% (OR=0.576, P=0.043) comparing Phase 1 and Phase 2 (formal introduction of risk stratification). The severity of complications also reduced. A significant decrease in complications for M=0 (i.e. minimal risk cases) was also identified comparing the current study (3.1%) to Phase 1 (7.2%) P=0.034. There was no change in postoperative complication risks (OR 0.812, P=0.434) or in mean postoperative CDVA (20/30, P=0.484) comparing current with Phase 1 outcomes.

CONCLUSION:

A simple preoperative risk stratification system, based on standard patient information gathered at preoperative consultation, appears to reduce intraoperative complications and support safer surgical training by appropriate allocation of higher risk cases.

PMID:
28666731
DOI:
10.1016/j.ajo.2017.06.014