The Association between Needle Size and Waste Product and Its Effect on Cost-Effectiveness of Botulinum Toxin Injections?

Clostridium botulinum toxin (BT) must be administered intramuscularly with a syringe, but dead space in the syringe-needle complex may cause product waste and result in cost implications for the patient and provider. Syringe dead space is the volume of residual fluid that remains within the syringe after the plunger is fully depressed during medication injection. We calculated the average volume of remaining product in a syringe-needle complex and cost loss implication of this volume of BT. This is a single-center, analytical study using saline and four different sized needles for analytics of waste product and cost-effectiveness. Syringes of 1 mL with attached 18, 21, 30, and 32-gauge (G) needles, respectively, were compared. The syringe-needle complex was weighed before drawing 0.05 mL of saline. The fluid was then discarded with the appropriate syringe and then weighed again. This procedure was repeated for the four needle types and the average difference in weight of the syringe-needle complex before and after saline waste was measured. The volume was converted to units of BT used in clinical practice and the cost of waste product evaluated. The mean difference in needle-syringe complex weight before and after intervention was 0.068, 0.056, 0.04, and 0.026 g for the 18, 21, 30, and 32G needles, respectively. We found a statistically significant difference comparing the 18G with the 30 and 32G (0.02 and 0.0007, respectively) and comparing the 21G with the 30 and 32G (0.0042 and 0.00002, respectively). When we extrapolated the data to BT units (4U/0.1 mL), we found that theoretically 2.72, 2.24, 1.6, and 1.04 units of BT are left in the syringe-needle complex for the 18, 21, 30, and 32G syringes, respectively. At a cost of $6.01/U of onabotulinum toxin A, we then calculated a provider loss of a gross average (mean) revenue of $96 and 62.4 per 10 syringes used with 30 and 32G needles. Needle size used for drawing up and administering BT has an effect on the amount of waste product and subsequently on cost-effectiveness.

Lacrimal tissue resection in Fasanella Servat operation and the correlation to dry eye.

Purpose: Fasanella-Servat operation (FSO) was previously reported to be associated with post-operative dry eyes due to accessory lacrimal gland resection during the surgery.We performed a retrospective, cohort study to determine the frequency of lacrimal tissue resection during FSO and its correlation with post-operative eye dryness and keratopathy.Methods: Review of all patients who underwent FSO at New York-Presbyterian Weill Cornell Hospital over a two-year period (2013-2015). Patients were included only if they had adequate histopathological specimens of the resected tissue obtained during surgery. Outcomes included the study of the pathological specimen for the presence of lacrimal tissue; Post-operative dry eye symptoms and pre- and post-operative corneal epitheliopathy.Results: 46 patients with a total of 58 eyelid resections were studied.Eight eyelids (13.7%) were found to have lacrimal tissue present in the pathology specimens.Postoperatively, nine patients reported some symptoms of dry eye and new-onset keratopathy was noted in four eyes (6.8%), only one of which had lacrimal tissue present in histopathology specimen obtained from surgery.Discussion: Previous studies found lacrimal tissue present in up to 43% of specimens resected during FSO. Our data found a lower rate of lacrimal tissue resection during FSO, and did not find an association between lacrimal tissue resection and post-operative dryness or epitheliopathy.Conclusion: Our study is one of few to examine histopathological resections from the FSO.We found that lacrimal tissue is not frequently resected during FSO, and when it is resected, there is no increased incidence of post-operative dryness or keratopathy.

Involutional entropion repair combining the modified Bick quick strip procedure with Quickert rotational sutures.

PURPOSE: The purpose of the study was to determine the results of involutional entropion repair by combining the modified Bick strip procedure with Quickert rotational sutures. METHODS: A retrospective review of consecutive patients with involutional entropion who underwent repair by combined Bick and Quickert technique from January 2013 to December 2017 was performed. RESULTS: A total of 43 cases of involutional entropion repair were preformed in this time period. Fourteen eyelids of 12 patients had the combined procedure. There were no failures with a median follow-up of 29 months. Mean operative time, recorded in 10 patients, was 15 ± 2.2 minutes. Complications were minimal. CONCLUSIONS: The combination of the modified Bick quick strip procedure and Quickert sutures requires minimal surgical dissection and provides excellent results for the treatment of involutional entropion.

Does long-term success from endoscopic DCR correlate with early post-operative reduction in tearing?

PURPOSE: The purpose of the study was to determine the association between early post-operative improvement in tearing and the long-term success rate of endoscopic dacryocystorhinostomy (eDCR). METHODS: A retrospective review of consecutive patients who underwent eDCR and were followed up for at least 6 months at our institution from January 2010 to December 2017 was performed. RESULTS: 47 cases(39 patients) of eDCR met the inclusion and exclusion criteria during this time period. Mean follow up after the surgery was 12.5 ±â€¯8 months. In 45 out of 47 (96%) cases post-operative improvement in epiphora within 2 weeks of surgery, or lack thereof, correlated with long-term success or failure of the procedure. There were only 2 cases in which the patients felt improvement in tearing at the initial post-operative visit and the tearing recurred in the late post-operative period (>6 months). CONCLUSIONS: There is a strong association between the early initial post-operative assessment of tearing resolution and the long-term result of eDCR.

Abducens nerve palsy after orbital decompression.

INTRODUCTION: Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED. AIM: We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery. RESULTS: Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring. DISCUSSION: Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.

Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy.

INTRODUCTION: Surgical rehabilitation of thyroid orbitopathy involves reducing proptosis, treating strabismus, lengthening the eyelids, and managing aesthetic changes. Not all are necessary in each patient; however, they often are. The current investigation intends to describe postdecompression changes that may influence the staging of these procedures. METHODS: In this retrospective cohort study, records of 169 patients who underwent orbital decompression between 1983 and 2001 were reviewed. A single orbital specialist confirmed all measurements. Time to follow up was defined as the most recent follow up after decompression and prior to any secondary procedures. No strabismus or eyelid surgery was performed at the time of decompression. Strabismus was measured with alternating prism cover test. Ductions were estimated utilizing Hirschberg's method. Exophthalmometry was measured with Hertel. Eyelid positions were defined relative to the pupillary light reflex. Strabismus data were analyzed within eye pairs. Ductions, exophthalmometry and eyelid position were analyzed for each eye. T-test for paired data was utilized to compare means pre- and postoperatively. RESULTS: The study population was on average 45 years old and 73.4% women. Average length of follow up was 1.2 years. Esotropia was significantly increased after decompression by an average of 8.1 prism diopters (p < 0.01). Exotropia and vertical deviations were not significantly altered. Ductions decreased by >5 degrees in at least one meridian for 68.1% of the population. Upper eyelid retraction remained unchanged; however, lower eyelid retraction improved by 50% from 1.4 mm to 0.7 mm (p < 0.01). Exophthalmometry improved from 23.5 mm to 19.7 mm (p < 0.01), and this result was correlated with the number of walls removed (Pearson r = -0.302, p < 0.01). CONCLUSIONS: On average, esotropia and ductions tend to worsen with decompression surgery. This result supports the clinical dictum to avoid strabismus surgery until after decompression. The improvement in lower eyelid retraction suggests that at least lower eyelid-lengthening surgery should be reserved for after decompression, as there may be significant spontaneous improvement, while the same may not be true for upper eyelid retraction, which does not tend to change with decompression.

Double Vision After Minimally Invasive Orbital Decompression.

INTRODUCTION: New onset Diplopia following orbital decompression in thyroid eye disease patients is estimated to occur in up to 30% to 40% of decompression patients, mostly related to deep lateral and medial wall decompressions. METHODS: A retrospective chart review of all minimally invasive (fat and minimal bone orbital decompression performed at the UCLA Stein Eye Institute between 2005 and 2015. Inclusion criteria were thyroid eye disease patients older than 18 years undergoing fat only orbital decompression with no previous muscle surgery. RESULTS: The chart review revealed only 5 patients with new onset diplopia after this surgery. The cases are discussed and a possible mechanism for the diplopia is proposed. DISCUSSION: Double vision following minimally invasive orbital decompression is rare and the mechanisms are poorly understood.

The success rate of TED upper eyelid retraction reoperations.

Although reoperation rates for upper lid retraction surgery for thyroid eye disease (TED) typically range between 8% and 23%, there is little literature describing the outcomes of these second operations. In this retrospective observational cohort study, all patients that underwent surgery for upper eyelid retraction over a 14-year period at a single institution were included. Cases were included if a second eyelid retraction surgery was performed during the study period. Success of surgery was defined as a marginal reflex distance (MRD1) of 2.5 to 4.5 mm in each eye and less than 1 mm difference in MRD1 between the eyes. Overcorrection and undercorrection were defined as above and below these bounds, respectively. 72 eyes in 49 patients were included in the study. The mean age was 56.6 (±11.5) years. By definition, all patients had at least 1 lid lengthening surgery for upper eyelid retraction, and at least 1 subsequent surgery. For this second surgery, 61 eyes (85%) underwent retraction surgery and 11 eyes (15%) underwent ptosis surgery. After this second operation, 31% were undercorrected and 33% were overcorrected. A third surgery was performed in 19 eyes (25%), 12 had surgery for residual retraction and 7 for ptosis. After the third operation 10% of eyes were under corrected and 11% were over corrected. Four patients underwent a fourth surgery: one for retraction and three for ptosis. Success was noted in 35% after the second surgery and 44% after the third. Surgical success in eyelid retraction surgery increases from a second to a third consecutive surgery, and residual asymmetry was roughly equally distributed between over- and undercorrection.

Original and generic latanoprost for the treatment of glaucoma and ocular hypertension: are they really the same?

We compared the intraocular pressure (IOP)-lowering effect and safety profile of latanoprost (Xalatan) with its generic variant, Glautan (Unipharm, Tel Aviv, Israel). After 1 and 4 weeks of treatment, a randomized, prospective, cross-over comparison was carried out that included patients with open-angle glaucoma or ocular hypertension, either naïve or treated and well-controlled, who were attending the Department of Ophthalmology, Tel Aviv Medical Centre, Tel Aviv, Israel, between May 2010 and November 2012. After a 3-week washout period for the medicated subjects, the participants were randomized to 4 weeks of treatment with either Xalatan or Glautan once every evening and then, after a 3-week washout period, crossed-over to the other treatment for an additional 4 weeks. Efficacy was expressed by a change in intraocular pressure at three designated hours of the day after 1 week and 1 month of treatment, and tolerability was determined by ocular side-effects as reported by the patient in a questionnaire. A total of 19 patients (mean age at initial diagnosis 66 ± 9 years, 14 females) were enrolled, of whom 17 had bilateral open-angle glaucoma and two had unilateral disease. Both drugs lowered intraocular pressure after 1 week and 1 month (P = 0.06 and P = 0.04, respectively) of treatment. Xalatan had a tendency of greater efficacy than Glautan both after 1 week and 1 month, but the difference was not statistically significant (P = 0.69 and P = 0.34, respectively). Drug safety was similar for Xalatan or Glautan, but more ocular side-effects were reported after treatment with Glautan (21 vs 12 for Xalatan, P = 0.06).

The effects of vital dyes on retinal pigment epithelium cells in oxidative stress.

PURPOSE: To determine the effect of the most commonly used vital dyes in vitrectomy [trypan blue at 0.15% concentration and indocyanine green (ICG) at 0.5% concentration] on the viability of human retinal pigment epithelium (RPE) cell lines (ARPE-19) exposed to oxidative stress. METHODS: ARPE-19 cells unexposed or exposed to oxidative stress (hypoxic chamber) were treated for 1 min with one of the dyes. RPE proliferation was measured by (3)H-thymidine incorporation, adhesion by ability to adhere to fibronectin, and safety by annexin V staining. RESULTS: Proliferation: The dyes affected the proliferation of RPE cells differently under non-hypoxic and hypoxic conditions (p = 0.001). In non-hypoxic conditions, there was no statistically significant difference between the proliferation of the treated (both dyes) and untreated RPE cells (p = 0.279). Under hypoxia, both dyes significantly suppressed proliferation, more so with ICG (p = 0.001). Adhesion: The dyes affected adhesion differently under non-hypoxic and hypoxic conditions (p = 0.04). In non-hypoxic conditions, both increased the adhesive properties of RPE cells to fibronectin, ICG more than trypan blue (p = 0.001). Under hypoxia, both dyes suppressed adhesion, with no statistically significant difference between treated and non-treated RPE cells. Apoptosis: Both dyes increased early apoptosis of RPE cells compared with no treatment (p = 0.001), ICG more than trypan blue. Hypoxia increased the apoptosis of both dyes compared to non-hypoxic conditions (p = 0.02). CONCLUSIONS: In hypoxic conditions, both dyes showed an inhibition of RPE adhesion to fibronectin and proliferation capacity and an increase in early apoptosis compared with non-hypoxic conditions. Apoptosis was greater in ICG-treated RPE cells than in trypan blue-treated cells.

Unexpected pathologies in patients referred for endoscopic DCR.

The objective of this study is to describe a series of patients with different pathologies mimicking nasolacrimal duct obstruction (NLDO), diagnosed with the use of a computed tomography (CT) scan prior to a scheduled endoscopic dacryocystorhinostomy (DCR). This study is a retrospective report. We reviewed the medical records of 47 consecutive patients (57 sides) with long-standing epiphora between 2007 and 2012. All patients were referred to our tertiary Medical Center with a diagnosis of NLDO and were expected to undergo endoscopic dacryocystorhinostomy (DCR). They all underwent routine sinus CT scan prior to surgery. All scans, as well as the demographic and medical characteristics of these patients were reviewed. Of all 47 patients enrolled, in 4 patients (7 % of all sides), unexpected pathologies, other than nasolacrimal system distention, inflammation or infection were identified preoperatively. These included squamous cell carcinoma of the lacrimal sac and nasolacrimal duct, rhinoscleroma at Hasner's valve region, a compressing ethmoidal mucocele and a case of dacryocystocele. These unusual pathologies mandated a different management and surgical approach. In all four cases, a preoperative CT scan helped in identifying the pathology and in localizing the lacrimal apparatus in relation to the paranasal sinuses. Different nasal, paranasal and lacrimal pathologies may mimic primary acquired NLDO. A high index of suspicion, a thorough clinical evaluation and utilizing preoperative imaging may lead to an alteration of patient management and to a completely different surgical approach.

Management and outcome of consecutive pregnancies complicated by idiopathic intracranial hypertension.

BACKGROUND: The effects of consecutive pregnancies on the course of idiopathic intracranial hypertension (IIH) are unclear in view of the scarce published data. OBJECTIVES: To evaluate the course and management of visual and pregnancy outcomes of consecutive pregnancies with IIH. METHODS: The medical records of women with IIH in consecutive pregnancies were reviewed for neuro-ophthalmological findings, management, and visual and pregnancy outcomes. RESULTS: The study group comprised eight women with at least two consecutive pregnancies (mean age 27.3 +/- 5.3 years). The mean duration of IIH prior to the first pregnancy was 3.4 +/- 3.16 years. One woman with IIH pre-pregnancy symptoms and three women with clinical features of IIH during the second trimester of pregnancy (gestational week 21.7 +/- 4.04) were treated with acetazolamide (250 mg every 8 hours). Symptoms resolved, resulting in uncomplicated first deliveries for all four. The first deliveries of four other women were by cesarean section due to obstetric indications. Only one woman developed symptoms and signs of IIH during her second pregnancy and was thus treated with acetazolamide. Two women who completed three pregnancies had no IIH symptoms during their pregnancies. The course and outcome of those pregnancies were normal. CONCLUSIONS: IIH apparently does not worsen or even become symptomatic in consecutive pregnancies. The appropriate management of IIH in pregnant women is similar to management for non-pregnant women; neither the course nor the obstetric outcome of first and consecutive pregnancies is influenced by the presence of IIH.

Neuro-Ophthalmologic Variability in Presentation of Genetically Confirmed Wolfram Syndrome: A Case Series and Review.

Wolfram syndrome is a neurodegenerative disorder caused by pathogenic variants in the genes WFS1 or CISD2. Clinically, the classic phenotype is composed of optic atrophy, diabetes mellitus type 1, diabetes insipidus, and deafness. Wolfram syndrome, however, is phenotypically heterogenous with variable clinical manifestations and age of onset. We describe four cases of genetically confirmed Wolfram syndrome with variable presentations, including acute-on-chronic vision loss, dyschromatopsia, and tonic pupils. All patients had optic atrophy, only three had diabetes, and none exhibited the classic Wolfram phenotype. MRI revealed a varying degree of the classical features associated with the syndrome, including optic nerve, cerebellar, and brainstem atrophy. The cohort's genotype and presentation supported the reported phenotype-genotype correlations for Wolfram, where missense variants lead to milder, later-onset presentation of the Wolfram syndrome spectrum. When early onset optic atrophy and/or diabetes mellitus are present in a patient, a diagnosis of Wolfram syndrome should be considered, as early diagnosis is crucial for the appropriate referrals and management of the associated conditions. Nevertheless, the condition should also be considered in otherwise unexplained, later-onset optic atrophy, given the phenotypic spectrum.

The rate of myocardial infarction events among patients with age-related macular degeneration: a population-based study.

PURPOSE: To examine the association between age-related macular degeneration (AMD) and the risk of myocardial infarctions (MIs) in a large health maintenance organization. DESIGN: A retrospective cohort study carried out at Maccabi Healthcare Services (MHS). PARTICIPANTS: A total of 6,546 patients aged ≥65 years who were diagnosed with AMD between April 18 1996 and June 6 2008, and 61,672 non-AMD patients frequency-matched for age and gender. METHODS: Participants were retrospectively followed to the day of leaving the MHS, to undergoing an MI, or to closure of the study on July 1 2008, whichever came earlier. The relative risk of MI associated with AMD was estimated using the Cox proportional hazard model. MAIN OUTCOME MEASURES: Incident myocardial infarction events. RESULTS: During the study period, there were 159 (5.1 per 1,000 person years [PY]) and 2,997 (4.2 per 1,000 PY) MIs respectively in the AMD and non-AMD patient groups. The age- and gender-adjusted hazard ratio (HR) of MI among AMD patients was 1.01 (95%CI: 0.85-1.20). Baseline medical characteristics associated with increased risk of mortality included diabetes mellitus, hypertension, older age, and male gender. The fully adjusted HR associated with AMD was 1.03 (95%CI: 0.87-1.22). CONCLUSION: Despite the shared risk factors associated with AMD and MIs, we found no increased risk of MI in AMD patients.

Steroids and the management of macular edema.

Macular edema (ME) is a condition which is usually secondary to an underlying disease process. It is most commonly seen following venous occlusive disease, diabetic retinopathy and posterior segment inflammatory disease. The treatment of ME varies, depending upon the underlying etiology, and has led to varying degrees of success. Traditionally, the main treatment options have included topical and systemic steroids, due to their known antiangiogenic, antiedematous, antiinflammatory and antiproliferative effects. This comprehensive review outlines the current use of steroids and highlights the ever-growing indications for steroids in ME secondary to various ocular conditions as well as the recent breakthrough results of the efficacy of this treatment.

[ECG changes during stroke].

In a patient, who presented with left sided hemiparesis and right frontal brain infarction, ischemic-like new T wave inversion appeared in a routine electrocardiogram (ECG), performed 2 days after admission. Chest pain or equivalent manifestations, suggesting acute coronary syndrome were denied, and normal troponin level was found. A literature search revealed that a variety of ECG changes might be seen in about 30% of patients with acute stroke. They arise from catecholamine induced myocte injury, and may pose a diagnosis dilemma in the differential diagnosis from ischemic ECG changes. The role of ECG changes in our patient and other patients with similar findings is yet to be determined.

The prevalence of glaucoma in patients undergoing surgery for eyelid entropion or ectropion.

PURPOSE AND DESIGN: The aim of this study was to establish the prevalence of known glaucoma in patients undergoing ectropion or entropion surgical repair. In this study, retrospective review of case series was performed. PARTICIPANTS: All patients who underwent ectropion or entropion surgery in a tertiary medical center between 2007 and 2014 were included. The etiology of eyelid malpositioning was involutional or cicatricial. METHODS: The medical files of the study participants were reviewed for the presence and type of glaucoma, medical treatment, duration of treatment, and the amount of drops per day. These data were compared to a matched control group of 101 patients who underwent blepharoplasty for dermatochalasis in the same department during the same period. MAIN OUTCOME MEASURE: In this study, the prevalence of glaucoma in individuals with ectropion or entropion was the main outcome measure. RESULTS: A total of 227 patients (57% men, mean age: 79.2 years) who underwent ectropion or entropion surgery comprised the study group and 101 patients who underwent upper blepharoplasty for dermatochalasis comprised the control group. Compared to four patients in the control group (4%, P=0.01), 30 of the study patients (13.2%) had coexisting glaucoma. Of 30 glaucomatous patients, 25 had primary open-angle glaucoma for a mean duration of 10.3 years. The glaucomatous patients were treated with an average of 2.7 antiglaucoma medications. CONCLUSION: An increased prevalence of known glaucoma in patients undergoing ectropion or entropion repair surgery was found. This observation may indicate that the chronic usage of topical anti-glaucoma eyedrops may lead to an increased risk of developing eyelid malpositions, especially in elderly patients.