Spontaneous Venous Pulsations Detected With Infrared Videography.

BACKGROUND: Assessment of spontaneous venous pulsation (SVP) is commonly undertaken to help determine whether intracranial pressure (ICP) is elevated. Previous studies using direct ophthalmoscopy or slit-lamp assessments have found that SVP is not observed in 67%-81% of subjects with normal ICP, and that interobserver agreement when grading SVP is poor. METHODS: Patients (n = 105) undergoing clinically indicated retinal OCT scans, who were all believed to have normal ICP, had 10-second infrared video recordings performed with the Heidelberg Spectralis OCT system (Heidelberg Engineering GmbH, Heidelberg, Germany). The presence and amplitude of SVP in each video was independently graded by 2 neuro-ophthalmologists. RESULTS: The 2 observers found SVP present in 97% and 98% of right eyes and in one or both eyes in 99% and 100% of subjects. Interobserver agreement was high (Cohen's kappa 0.82 for right eyes). Optic discs with a smaller cup had a significantly lower SVP amplitude (Spearman's rho = 0.22, P = 0.02). CONCLUSIONS: Infrared video is widely available in eye clinics by the use of OCT imaging systems and is substantially more sensitive in detecting SVP than traditional assessments using ophthalmoscopy. SVP is absent in as few as 1% of people with presumed normal ICP.

Association of Intracranial Pressure and Spontaneous Retinal Venous Pulsation.

Importance: A convenient and reliable method for noninvasive intracranial pressure assessments is desirable to reduce the need for invasive procedures (eg, intracranial pressure monitoring and lumbar punctures) and allow clinicians to identify and treat patients with intracranial hypertension in a timely manner. Objective: To determine whether infrared video assessment of spontaneous retinal venous pulsation is associated with intracranial pressure and is a valid tool to indicate the presence or absence of raised intracranial pressure in patients without papilledema. Design, Setting, and Participants: A single-center prospective study was conducted at a tertiary referral center between January 2017 and May 2018. Patients consecutively admitted for clinically indicated elective 24-hour invasive intracranial pressure monitoring had ophthalmic review including infrared video recording of their spontaneous venous pulsation. Two neuro-ophthalmologists, who were masked to the intracranial pressure monitoring results, independently graded the spontaneous venous pulsation (grade 0 to 3). Analysis began in June 2018. Main Outcomes and Measures: The association between simultaneously recorded intracranial pressure and spontaneous venous pulsation (binary variable: present/absent) assessed through retinal infrared video recordings was evaluated using a multiple linear regression model. Results: Of 105 patients, the mean (SD) age was 39 (14) years, and 79 (75%) were women. The mean (SD) simultaneous intracranial pressure was 1 (5) mm Hg for 91 patients (86.7%) with spontaneous venous pulsations and 13 (14) mm Hg for 14 patients (13.3%) without spontaneous venous pulsations. A multiple linear regression model adjusted for 7 potential confounders confirmed a statistically significant association between intracranial pressure and spontaneous venous pulsation (ß = -9.1; 95% CI, -13.7 to -4.6; P < .001; adjusted R2 = 0.42). Conclusions and Relevance: The absence of spontaneous venous pulsation on retinal infrared video recordings is significantly associated with higher levels of intracranial pressure and should raise the suspicion of intracranial hypertension.

Internist diagnosis and management of chronic hepatitis B virus infection.

Chronic infection with the hepatitis B virus can lead to hepatocellular carcinoma and cirrhosis in up to 25% of infected individuals. As many as 2 million individuals in the US may have chronic hepatitis B infection, most of whom immigrated to the US from hepatitis B-endemic regions of the world. A 2010 report from the Institute of Medicine noted that two thirds of patients with hepatitis B are unaware of their infection, and most health care providers do not screen for hepatitis B or know how to manage hepatitis B-positive patients. In 2010, the Hepatitis B Foundation convened a group of primary care providers to consider the existing evidenced-based recommendations and strategies for implementation of hepatitis B screening into routine practice. The group designed an easy-to-use algorithm for screening, initial evaluation, ongoing management, and referral to a subspecialist when appropriate. Internal medicine specialists, including primary care providers and subspecialists, need to understand the steps they can take to address this often under-recognized disorder.

Chronic hepatitis B infection: a workshop consensus statement and algorithm.

Here, presented with an evidence-based algorithm, are workshop consensus recommendations on whom to screen for hepatitis B and when to pursue further evaluation and management.