The efficacy of Viscocanalostomies and combined phacoemulsification with Viscocanalostomies in the treatment of patients with glaucoma: a non-randomised observational study.

BACKGROUND: To evaluate the outcomes of Viscocanalostomy (VC) and Phacoviscocanalostomy (PV) in controlling primary and secondary glaucoma in a large cohort of patients from a single eye unit and performed by a single surgeon. METHODS: This non-randomised, retrospective study was conducted on 620 eyes of 458 patients. All patients who had either viscocanalostomy (VC) or combined phacoemulsification and viscocanalostomy (PV) over a three-year period were included. Intraocular pressures (IOP), number of anti-glaucoma medications used, and any complications were recorded over a 3-year follow up period. Paired T-Test was used to compare preoperative and post-operative IOP at specified time points. Kaplan-Meier survival models were used to determine success rates over the study period. RESULTS: Six hundred twenty procedures were performed during the 3-year study period, of which 427 were PV and 193 VC. The mean follow-up was 31.8 months. Overall complete success (IOP ≤ 21 mmHg, without medication) at 3 years was achieved in 65.7% of patients, with qualified success (IOP ≤21 mmHg with or without medication) achieved in 96.0%. Subgroup analysis showed complete success rate of 76.0% for PV and 63.1% for VC (p = 0.005), with qualified success 95.9% for PV and 94.0% for VC (p = 0.668). Mean pre-operative IOP (mmHg) for all procedures was 23.02 ± 5.6, with PV and VC subgroups at 22.54 ± 5.10 and 24.06 ± 6.45. Post-operatively IOP at month 12 and 36 was 14.74 ± 3.57 and 14.40 ± 3.17 respectively for all procedures, 14.62 ± 3.26 and 14.44 ± 3.10 for PV, and 15.03 ± 4.18 and 14.31 ± 3.33 for VC. Across all procedures, pre-operatively an average of 3.05 ± 0.96 anti-glaucoma medications were used. This reduced to 0.13 ± 0.39 in 12 months and 0.38 + 0.71 by 36 months. Sixty-five cases had complications due to trabeculo-Descemet window perforation during viscocanalostomy with 7 cases developing complications from the cataract element. In the 12.9% of patients who had complications there were no differences of IOP noted at 3 years. CONCLUSION: VC and PV have good IOP lowering capacity and are both effective at sustaining a reduction in IOP at 3 years. PV achieved a higher success rate without medication. The low complication profile with reduced post-operative care means these procedures may be a preferred option for early surgical intervention.

Folded bandage contact lens retention in a patient with bilateral dry eye symptoms: a case report.

BACKGROUND: Bandage contact lenses are commonly used by ophthalmic practitioners to protect the patient's cornea. We report a case of folded bandage contact lens retained for six and a half years in the upper subtarsal space. To our knowledge, no other cases of retained bandage contact lens have previously been reported in the literature. CASE PRESENTATION: A patient was applied a pair of bandage contact lenses due to persistent ocular pain secondary to dry eye symptoms. At her subsequent visit, bandage contact lens was removed from her left eye, but none was found in the right eye. Documentation from further visit stated that the bandage contact lenses were no longer in situ. 6.5 years since the lens insertion, lid eversion revealed a 'foreign body' retained beneath her right upper eyelid, which was noted to be a folded, discoloured bandage contact lens. CONCLUSIONS: The 'upper fornix trap', where the contact lens may be retained by the upper tarsal edge, presents an anatomical hazard for contact lens users. Moreover, soft contact lenses may be more likely to retain asymptomatically and to fold onto itself compared to hard lenses. Our case report highlights the importance of performing a thorough eye examination, which includes double eversion of the upper eyelids and sweeping of the fornices with cotton buds, and maintaining clinical suspicion of contact lens retention.

Yersinia pestis Ail recruitment of C4b-binding protein leads to factor I-mediated inactivation of covalently and noncovalently bound C4b.

The outer membrane protein Ail of Yersinia pestis mediates several virulence functions, including serum resistance. Here, we demonstrate that Ail binds C4b-binding protein (C4BP), the primary fluid-phase regulator of the classical and lectin pathways. Non-covalent binding of C4 and C4b to Ail was also observed. C4BP bound to Ail can act as a cofactor to the serine protease factor I (fI) in the cleavage of fluid-phase C4b. Employing a panel of C4BP alpha-chain mutants, we observed that the absence of complement control protein domain 6 and 8 reduced binding to Ail. Immunoblot analysis of normal human serum (NHS)-treated bacteria revealed minimal C4b alpha'-chain complexes with bacterial outer membrane targets. Addition of the anti-C4BP monoclonal antibody MK104 to NHS restored C4b-alpha' chain target complexes, suggesting that C4b binds covalently to targets on the Y. pestis surface. C4b bound to Ail noncovalently was also cleaved in a C4BP and fI-dependent manner, leaving the C4c fragment bound to Ail. MK104 also prevented the cleavage of noncovalently bound C4b. Collectively, these data suggest that when C4BP is bound to Ail, fI can cleave and inactivate C4b that has bound covalently to bacterial surface structures as well as C4b bound noncovalently to Ail.

Yersinia pestis Ail recruitment of C4b-binding protein leads to factor I-mediated inactivation of covalently and noncovalently bound C4b.

The outer membrane protein Ail of Yersinia pestis mediates several virulence functions, including serum resistance. Here, we demonstrate that Ail binds C4b-binding protein (C4BP), the primary fluid-phase regulator of the classical and lectin pathways. Noncovalent binding of C4 and C4b to Ail was also observed. C4BP bound to Ail can act as a cofactor to the serine protease factor I (fI) in the cleavage of fluid-phase C4b. Employing a panel of C4BP alpha-chain mutants, we observed that the absence of complement control protein domain 6 and 8 reduced binding to Ail. Immunoblot analysis of normal human serum (NHS)-treated bacteria revealed minimal C4b alpha'-chain complexes with bacterial outer membrane targets. Addition of the anti-C4BP monoclonal antibody MK104 to NHS restored C4b-alpha' chain target complexes, suggesting that C4b binds covalently to targets on the Y. pestis surface. C4b bound to Ail noncovalently was also cleaved in a C4BP and fI-dependent manner, leaving the C4c fragment bound to Ail. MK104 also prevented the cleavage of noncovalently bound C4b. Collectively, these data suggest that when C4BP is bound to Ail, fI can cleave and inactivate C4b that has bound covalently to bacterial surface structures as well as C4b bound noncovalently to Ail.

The Yersinia pseudotuberculosis outer membrane protein Ail recruits the human complement regulatory protein factor H.

Previous investigations characterizing the mechanism(s) of complement resistance in Yersinia pseudotuberculosis showed that the outer membrane protein Ail can functionally recruit the regulator of the classical and lectin pathways of complement, C4b-binding protein. In this study, we extend these observations and show that Ail can also recruit the regulator of the alternative pathway (AP), factor H (fH). Binding to fH was dependent on Ail expression and observed in the context of full-length LPS. Inactivation of ail resulted in loss of fH binding. Ail expression conferred resistance to AP-mediated killing. Bound fH was functional as a cofactor for factor I-mediated cleavage and inactivation of C3b. Ail alone is sufficient to mediate fH binding and resistance to AP-mediated killing, because Ail expression in a laboratory Escherichia coli strain conferred both of these phenotypes. Binding was specific and inhibited by increasing heparin and NaCl concentrations. Using a panel of fH recombinant fragments, we observed that both short consensus repeats 5-7 and 19-20 regions are responsible for mediating the interaction with Ail. Collectively, these results suggest that fH recruitment is an additional mechanism of complement resistance of Ail. Recruitment of both fH and C4BP by Ail may confer Y. pseudotuberculosis with the ability to resist all pathways of complement activation.

Functional recruitment of the human complement inhibitor C4BP to Yersinia pseudotuberculosis outer membrane protein Ail.

Ail is a 17-kDa chromosomally encoded outer membrane protein that mediates serum resistance (complement resistance) in the pathogenic Yersiniae (Yersinia pestis, Y. enterocolitica, and Y. pseudotuberculosis). In this article, we demonstrate that Y. pseudotuberculosis Ail from strains PB1, 2812/79, and YPIII/pIB1 (serotypes O:1a, O:1b, and O:3, respectively) can bind the inhibitor of the classical and lectin pathways of complement, C4b-binding protein (C4BP). Binding was observed irrespective of serotype tested and independently of YadA, which is the primary C4BP receptor of Y. enterocolitica. Disruption of the ail gene in Y. pseudotuberculosis resulted in loss of C4BP binding. Cofactor assays revealed that bound C4BP is functional, because bound C4BP in the presence of factor I cleaved C4b. In the absence of YadA, Ail conferred serum resistance to strains PB1 and YPIII, whereas serum resistance was observed in strain 2812/79 in the absence of both YadA and Ail, suggesting additional serum resistance factors. Ail from strain YPIII/pIB1 alone can mediate serum resistance and C4BP binding, because its expression in a serum-sensitive laboratory strain of Escherichia coli conferred both of these phenotypes. Using a panel of C4BP mutants, each deficient in a single complement control protein domain, we observed that complement control protein domains 6-8 are important for binding to Ail. Binding of C4BP was unaffected by increasing heparin or salt concentrations, suggesting primarily nonionic interactions. These results indicate that Y. pseudotuberculosis Ail recruits C4BP in a functional manner, facilitating resistance to attack from complement.

Bilateral Cystoid Macular Edema and Corneal Endothelial Graft Rejection following Influenza and Varicella-Zoster Vaccinations.

PURPOSE: Multiple cases of corneal graft rejection after various vaccinations have been reported over the past decades. Here we described a case of bilateral cystoid macular edema (CME) and endothelial rejection in a DSAEK patient following influenza and varicella vaccines. CASE REPORT: A 72-year-old woman with bilateral Fuch's endothelial dystrophy received bilateral DSAEK surgeries. She received an influenza vaccination and her left visual acuity (VA) decreased due to CME. Half a year later, the patient received a varicella-zoster virus vaccine. 11 days later, she was found to have signs of endothelial graft rejection in both eyes. Unfortunately, her vision further deteriorated despite intensive topical steroid treatment. CONCLUSIONS: In view of the current worldwide efforts on mass vaccination against the COVID-19 pandemic, we suggest an increased use of topical corticosteroids both before and after vaccination may be helpful in reducing this risk.

Human complement factor H binds to outer membrane protein Rck of Salmonella.

Serum resistance, or resistance to complement-mediated killing, is a key virulence property of microbial pathogens. Rck is a 17-kDa outer membrane protein encoded on the virulence plasmid of Salmonella enterica serovars Typhimurium and Enteritidis. When expressed in either Escherichia coli or S. enterica Typhimurium, Rck confers serum resistance independent of LPS length. Recently, the Rck homolog from Yersinia enterocolitica, Ail, has been shown to bind the complement regulatory protein factor H (fH). Based on these observations, we hypothesized that Rck may also possess this ability. Using both flow cytometery and direct binding analysis, we demonstrate that Rck expressed in E. coli binds fH. We observed fH binding to Rck from human serum and also using the purified protein. Expression of Rck protected bacteria from alternative pathway-mediated killing and was associated with a reduction in C3b, Bb, and membrane attack complex deposition. fH bound to Rck promoted C3b cleavage in the presence of factor I. Binding was specific and mediated by two regions in fH, the short consensus repeats 5-7 and 19 to 20. These results suggest that fH recruitment by Rck is functional and can protect a normally serum-sensitive heterologous host against complement attack. Binding and exploitation of fH may thus contribute to Rck-mediated serum resistance.

Anesthetic Management of a Super Morbidly Obese Obstetric Patient With a Body Mass Index of 109 kg/m2 Presenting for Her Fourth Caesarean Delivery.

Morbidly obese obstetric patients undergoing anesthesia present many unique challenges. Previous caesarean sections (CSs) further complicate their management. We present the successful anesthetic management of a super morbidly obese obstetric patient with body mass index (BMI) of 109 kg/m2 who underwent her fourth CS. As per our review, this patient has the highest recorded BMI in the obstetric anesthesia literature. A 27-year-old female, G4P3003, presented for fourth repeat CS at 38 weeks' gestation. She had obstructive sleep apnea, hypertension, atrial fibrillation, and type 2 diabetes. Her first CS was emergent under general anesthesia (GA), and the other two were performed under neuraxial anesthesia, with the most recent one complicated by intraoperative cardiac arrest requiring cardiopulmonary resuscitation. Preoperative preparation involved multidisciplinary preparation, planning, and risk stratification. Although neuraxial anesthesia is preferred over GA for CS, she refused neuraxial anesthesia due to her prior traumatic experience and the potential that it caused her prior cardiac arrest. In addition, her inability to position for a block or lay flat, poor anatomical landmarks, unknown length of surgery, plan for periumbilical incision, uncertain placental status, and risk of massive hemorrhage convinced us to consider GA. Surprisingly, her airway examination was reassuring. Two 18G peripheral intravenous lines and an arterial line were obtained prior to induction. With optimum patient positioning and preoxygenation, modified rapid sequence induction with mask ventilation and endotracheal intubation with direct laryngoscopy were performed. A healthy baby was delivered without significant intraoperative complications. Intraoperative lung-protective strategy with recruitment maneuvers, multimodal analgesia, and elective postoperative continuous positive airway pressure aided in successful extubation. Postoperatively, pulmonary toilet, early mobilization, physical therapy, and venous thromboembolism prophylaxis were employed. Her postoperative course was complicated by severe preeclampsia and pulmonary embolism, which were managed successfully in the intensive care unit. She was discharged initially to outpatient rehabilitation followed by home. This case highlights the complexities and significance of an individualized approach in managing super morbidly obese obstetric patients.

Technique for Tube Extender Implantation.

PURPOSE: To describe a novel technique to facilitate Tube Extender implantation. MATERIALS AND METHODS: Two Tube Extender implantations were performed on 2 eyes of 2 patients. RESULTS: Before implanting the Tube Extender onto the cut tube of the glaucoma drainage device, a 30-G cannula, coated with viscoelastic, is threaded through the distal end of the extender and emerges from the proximal end. The cannula, with the extender laced over it, is then inserted into the cut tube, and the surgeon slides the Tube Extender down the cannula for insertion onto the cut tube. CONCLUSIONS: Retraction of the glaucoma drainage device from the anterior chamber occurs for various reasons, often the growth of the globe in pediatric patients. Tube Extenders can be implanted to lengthen the glaucoma drainage device to reenter the anterior chamber. However, the surgical technique can often be technically difficult to perform due to the flexibility of the glaucoma drainage device tube. We present a novel technique for Tube Extender implantation that makes the procedure easier to perform.

Anterior Chamber Pathology in Alagille Syndrome.

BACKGROUND: Alagille syndrome is an autosomal dominant disorder characterized by neonatal cholestasis, characteristic facies, and cardiac abnormalities. Ocular abnormalities include posterior embryotoxon, mosaic pattern of iris stromal hypoplasia, microcornea, optic disc drusen, and pigmentary retinopathy. We present the second report of ocular pathology in two cases of Alagille syndrome. METHODS: Gross and histologic preparations of four eyes of two patients. RESULTS: Posterior embryotoxon is seen in both cases, with iris processes extending to the embryotoxon in case 1. Case 1 exhibited distinctly abnormal iris stroma with a prominent cleft separating the anterior and posterior stroma. Lacy vacuolization of the iris pigment epithelium was seen in case 2. CONCLUSIONS: Alagille syndrome is primarily a hepatic disorder but presents with several distinct ocular pathologic features, most specifically posterior embryotoxon. This and the unusual iris stroma may be caused by improper migration of neural crest cells due to mutation in the Jagged 1 gene that causes Alagille syndrome. Patients with Alagille syndrome rarely present to ocular autopsy. Pathology findings may help us better understand the pathophysiology of the ocular abnormalities in this disorder.

Antibiotic Resistance in Streptococcus pneumoniae after Azithromycin Distribution for Trachoma.

Trachoma is caused by Chlamydia trachomatis and is a leading cause of blindness worldwide. Mass distribution of azithromycin (AZM) is part of the strategy for the global elimination of blinding trachoma by 2020. Although resistance to AZM in C. trachomatis has not been reported, there have been concerns about resistance in other organisms when AZM is administered in community settings. We identified studies that measured pneumococcal prevalence and resistance to AZM following mass AZM provision reported up to 2013 in Medline and Web of Science databases. Potential sources of bias were assessed using the Cochrane Risk of Bias Tool. A total of 45 records were screened, of which 8 met the inclusion criteria. We identified two distinct trends of resistance prevalence, which are dependent on frequency of AZM provision and baseline prevalence of resistance. We also demonstrated strong correlation between the prevalence of resistance at baseline and at 2-3 months (r = 0.759). Although resistance to AZM in C. trachomatis has not been reported, resistance to this commonly used macrolide antibiotic in other diseases could compromise treatment. This should be considered when planning long-term trachoma control strategies.

Functional recruitment of human complement inhibitor C4B-binding protein to outer membrane protein Rck of Salmonella.

Resistance to complement mediated killing, or serum resistance, is a common trait of pathogenic bacteria. Rck is a 17 kDa outer membrane protein encoded on the virulence plasmid of Salmonella enterica serovars Typhimurium and Enteritidis. When expressed in either E. coli or S. enterica Typhimurium, Rck confers LPS-independent serum resistance as well as the ability to bind to and invade mammalian cells. Having recently shown that Rck binds the inhibitor of the alternative pathway of complement, factor H (fH), we hypothesized that Rck can also bind the inhibitor of the classical and lectin pathways, C4b-binding protein (C4BP). Using flow cytometry and direct binding assays, we demonstrate that E. coli expressing Rck binds C4BP from heat-inactivated serum and by using the purified protein. No binding was detected in the absence of Rck expression. C4BP bound to Rck is functional, as we observed factor I-mediated cleavage of C4b in cofactor assays. In competition assays, binding of radiolabeled C4BP to Rck was reduced by increasing concentrations of unlabeled protein. No effect was observed by increasing heparin or salt concentrations, suggesting mainly non-ionic interactions. Reduced binding of C4BP mutants lacking complement control protein domains (CCPs) 7 or 8 was observed compared to wt C4BP, suggesting that these CCPs are involved in Rck binding. While these findings are restricted to Rck expression in E. coli, these data suggest that C4BP binding may be an additional mechanism of Rck-mediated complement resistance.

lgtC expression modulates resistance to C4b deposition on an invasive nontypeable Haemophilus influenzae.

We have previously shown that C3 binding to serum-resistant nontypeable Haemophilus influenzae (NTHi) strain R2866 is slower than C3 binding to a serum-sensitive strain. Ab-dependent classical pathway activation is required for complement-dependent killing of NTHi. To further characterize the mechanism(s) of serum resistance of R2866, we compared binding of complement component C4b to R2866 with a serum-sensitive variant, R3392. We show that C4b binding to R2866 relative to R3392 was delayed, suggesting regulation of the classical pathway of complement. Increased C4b deposition on R3392 was independent of the amount and subclass of Ab binding, suggesting that an impediment to C4b binding existed on R2866. Immunoblotting and mass spectrometry indicated that lipooligosaccharide and outer membrane proteins P2 and P5 were targets for C4b. P2 and P5 sequences and expression levels were similar in both strains. Insertional inactivation of the phase-variable lipooligosaccharide biosynthesis gene lgtC in R2866 augmented C4b deposition to levels seen with R3392 and rendered the bacteria sensitive to serum and whole blood. These results suggest a direct role of lgtC expression in the inhibition of C4b deposition and consequent serum resistance of R2866. Alteration of surface glycans of NTHi may be a critical event in determining the ability of a strain to evade host defenses and cause disseminated infection.

Role of lgtC in resistance of nontypeable Haemophilus influenzae strain R2866 to human serum.

We are investigating a nontypeable Haemophilus influenzae (NTHI) strain, R2866, isolated from a child with meningitis. R2866 is unusually resistant to killing by normal human serum. The serum 50% inhibitory concentration (IC50) for this strain is 18%, approaching that of encapsulated H. influenzae. R3392 is a derivative of R2866 that was found to have increased sensitivity to human serum (IC50, 1.5%). Analysis of tetrameric repeat regions within lipooligosaccharide (LOS) biosynthetic genes in both strains indicated that the glycosyltransferase gene lgtC was out of frame ("off") in most colonies of R3392 but in frame with its start codon ("on") in most colonies of the parent. We sought antigenic and biochemical evidence for modification of the LOS structure. In a whole-cell enzyme-linked immunosorbent assay, strain R3392 displayed reduced binding of the Galalpha1,4Gal-specific monoclonal antibody 4C4. Mass spectrometry analysis of LOS from strain R2866 indicated that the primary oligosaccharide glycoform contained four heptose and four hexose residues, while that of R3392 contained four heptose and three hexose residues. We conclude that the R2866 lgtC gene encodes a galactosyltransferase involved in synthesis of the 4C4 epitope, as in other strains, and that expression of lgtC is associated with the high-level serum resistance that has been observed for this strain. This is the first description of the genetic basis of high-level serum resistance in NTHI, as well as the first description of LOS composition in an NTHI strain for which the complete genome sequence has been determined.

RNA-protein interactions promote asymmetric sorting of the ASH1 mRNA ribonucleoprotein complex.

In Saccharomyces cerevisiae, ASH1 mRNA is localized to the tip of daughter cells during anaphase of the cell cycle. ASH1 mRNA localization is dependent on four cis-acting localization elements as well as Myo4p, She2p, and She3p. Myo4p, She2p, and She3p are hypothesized to form a heterotrimeric protein complex that directly transports ASH1 mRNA to daughter cells. She2p is an RNA-binding protein that directly interacts with ASH1 cis-acting localization elements and associates with She3p. Here we report the identification of seven She2p mutants-N36S, R43A, R44A, R52A, R52K, R63A, and R63K-that result in the delocalization of ASH1 mRNA. These mutants are defective for RNA-binding activity but retain the ability to interact with She3p, indicating that a functional She2p RNA-binding domain is not a prerequisite for association with She3p. Furthermore, the nuclear/cytoplasmic distribution for the N36S and R63K She2p mutants is not altered, indicating that nuclear/cytoplasmic trafficking of She2p is independent of RNA-binding activity. Using the N36S and R63K She2p mutants, we observed that in the absence of She2p RNA-binding activity, neither Myo4p nor She3p is asymmetrically sorted to daughter cells. However, in the absence of She2p, Myo4p and She3p can be asymmetrically segregated to daughter cells by artificially tethering mRNA to She3p, implying that the transport and/or anchoring of the Myo4p/She3p complex is dependent on the presence of associated mRNA.