Multimodal imaging in diabetic retinopathy and macular edema: An update about biomarkers.

Diabetic macular edema (DME), defined as retinal thickening near, or involving the fovea caused by fluid accumulation in the retina, can lead to vision impairment and blindness in patients with diabetes. Current knowledge of retina anatomy and function and DME pathophysiology has taken great advantage of the availability of several techniques for visualizing the retina. Combining these techniques in a multimodal imaging approach to DME is recommended to improve diagnosis and to guide treatment decisions. We review the recent literature about the following retinal imaging technologies: optical coherence tomography (OCT), OCT angiography (OCTA), wide-field and ultrawide-field techniques applied to fundus photography, fluorescein angiography, and OCTA. The emphasis will be on characteristic DME features identified by these imaging technologies and their potential or established role as diagnostic, prognostic, or predictive biomarkers. The role of artificial intelligence in the assessment and interpretation of retina images is also discussed.

Comments on "The surgical approach of late-onset tracheoesophageal fistula in a tracheostomized COVID-19 patient".

Dear Editor, we have read with interest the case reported by Rotolo et al.  (published in February 2023 as Early Access) concerning the surgical management of tracheoesophageal fistula (TEF) in a COVID-19 patient treated with prolonged mechanical ventilation for severe respiratory failure.

A Practical Guide for Using the EZ-Blocker Endobronchial Blocker: Tips and Tricks After 10 Years of Experience.

The EZ-Blocker (EZB) is a "Y-shaped," semirigid endobronchial blocker used for lung isolation and one-lung ventilation during thoracic surgery. Like many medical tools, initial efforts to use this endobronchial blocker may prove challenging for the uninitiated. However, some tips and tricks can be applied fairly rapidly to aid the clinician in properly placing the device, and, furthermore, may help the clinician get the most out of this innovative device. This article focuses on some of the technical aspects of its placement that the authors have developed over time. Additionally, other facets and potential pitfalls are discussed that relate to intraprocedural issues that may sometimes arise when using this device. The following aspects of the EZB as a lung-isolation device are discussed: standard positioning techniques, alternative positioning techniques, use in pediatric patients, approaches to achieving exceptional lung isolation, advanced uses, and limitations and potential issues. Although some information was taken from the authors' rather extensive experience with using this endobronchial blocker, some of the relevant literature are also reviewed, with the goal of being to improve the reader's knowledge of the device and improve the likelihood of its successful placement. The underlying design of the EZB remains unique among commercially available bronchial blockers in improving positional stability. The Y-shaped conformation, however, can lead to challenges when positioning the device in some patients. Therefore, some very practical tips and tricks are provided to assist the clinician in correctly positioning the device and other hints to improve the quality of lung isolation and surgical conditions.

The safety of thoracic paravertebral block and erector spinae plane block in patients treated with anticoagulant or antiplatelet therapy. A narrative review of the evidence.

INTRODUCTION: The management of thoracic paravertebral block (TPVB) and erector spine plane block (ESPB) in patients treated with anticoagulant or antiplatelet therapy is based on limited clinical data, mostly from single case reports. Scientific societies and organizations do not provide strong detailed indications about the limitations of these regional anesthesia techniques in patients receiving antithrombotic therapy. This review summarizes evidence regarding TPVB and ESPB in patients under antithrombotic therapy. EVIDENCE ACQUSITION: A literature review from PubMed/MEDLINE, EMBASE, Cochrane, Google Scholar and Web of Science databases was conducted from 1999 to 2022 to identify articles concerning TPVB and ESPB for cardio-thoracic surgery or thoracic procedures in patients under anticoagulant or antiplatelet therapy. EVIDENCE SYNTHESIS: A total of 1704 articles were identified from the initial search. After removing duplicates and not-pertinent articles, 15 articles were analyzed. The results demonstrated a low risk of bleeding for TPVB and minimal or absent risk for ESPB. Ultrasound guidance was extensively used to perform ESPB, but not for TPVB. CONCLUSIONS: Although the low level of evidence available, TPVB and ESPB are reasonably safe options in patients ineligible for epidural anesthesia due to antithrombotic therapy. The few published studies suggest that ESPB offers a risk profile safer than TPVB and the use of ultrasound guidance minimizes any complication. Since the literature available does not allow us to draw definitive conclusions, future adequately-powered trials are warranted to determine the indications and the safety of TPVB and ESPB in patients receiving anticoagulant or antiplatelet therapy.

Preoperative SARS-CoV-2 Infection Screening before Thoracic Surgery during COVID-19 Pandemic: A Multicenter Retrospective Study.

Objectives: During coronavirus disease (COVID-19) pandemic, preoperative screening before thoracic surgery is paramount in order to protect patients and staff from undetected infections. This study aimed to determine which preoperative COVID-19 screening tool was the most effective strategy before thoracic surgery. Methods: This retrospective cohort multicenter study was performed at 3 Italian thoracic surgery centers. All adult patients scheduled for thoracic surgery procedures from 4th March until 24th April, 2020, and submitted to COVID-19 preoperative screenings were included. The primary outcome was the yield of screening of the different strategies. Results: A total of 430 screenings were performed on 275 patients; 275 anamnestic questionnaires were administered. 77 patients were screened by an anamnestic questionnaire and reverse transcriptase polymerase chain reaction (RT-PCR). 78 patients were selected to combine screening with anamnestic questionnaire and chest computed tomography (CT). The positive yield of screening using a combination of anamnestic questionnaire and RT-PCR was 7.8% (95% CI: 2.6-14.3), while using a combination of anamnestic questionnaire and chest CT was 3.8% (95% CI: 0-9). Individual yields were 1.1% (95% CI: 0-2.5) for anamnestic questionnaire, 5.2% (95% CI: 1.3-11.7) for RT-PCR, and 3.8% (95% CI: 0-9). Conclusions: The association of anamnestic questionnaire and RT-PCR is able to detect around 8 positives in 100 asymptomatic patients. This combined strategy could be a valuable preoperative SARS-CoV-2 screening tool before thoracic surgery.

Practical guidance for imaging biomarkers in exudative age-related macular degeneration.

We provide an overview of current macular imaging techniques and identify and describe biomarkers that may be of use in the routine management of macular diseases, particularly exudative age-related macular degeneration (AMD). This perspective includes sections on macular imaging techniques including optical coherence tomography (OCT) and OCT angiography (OCTA), classification of exudative AMD, and biomarkers in structural OCT and OCTA. Fluorescein angiography remains a vital tool for assessing the activity of neovascular lesions, while indocyanine green angiography is the preferred option for choroidal vessel imaging in neovascular AMD. OCT provides a non-invasive three-dimensional visualization of retinal architecture in vivo and is useful in the diagnosis of many imaging biomarkers of AMD-related neovascular lesions, including lesion activity. OCTA is a recent advance in OCT technology that allows accurate visualization of retinal and choroidal vascular flow. OCT and OCTA have led to an updated classification of exudative AMD lesions and provide several biomarkers that help to establish a diagnosis and the disease activity status of neovascular lesions. Individualization of therapy guided by OCT and OCTA biomarkers has the potential to further improve visual outcomes in exudative AMD. Moving forwards, integration of technologically-advanced imaging equipment with AI software will help ophthalmologists to provide patients with the best possible care.

Persistent alveolar air leak following pulmonary lobectomy: an old problem in a modern era.

Persistent alveolar air leak (PAAL) after major lung resection remains a common complication in thoracic surgery. The aim of this study was to identify a subset of patients with high risk of developing PAAL after pulmonary lobectomy. Another objective was to evaluate the influence of PAAL on postoperative complications and length of hospital stay. A retrospective analysis on 895 patients undergoing pulmonary lobectomy from January 2014 to December 2019 was performed. PAAL was defined as air leak lasting more than 5 days after lung surgery. Univariate analyses and logistic regressions were performed to identify the predictors of PAAL. A backward selection algorithm was used to identify the optimal set of predictors. The incidence of PAAL was 8.2% (74/895). Male gender (p=0.017), BMI (p<0.001), transient ischemic attack (p=0.031), FEV1 (p=0.018), lobectomy combined with adjacent subsegmentectomy (p=0.018), partial and extended pleural adhesions (p=0.033 and p=0.038, respectively) were identified as independent risk factors for PAAL through logistic regression. A weak positive correlation was found between video-assisted thoracic surgery (VATS) and PAAL following pulmonary lobectomy (p=0.100). PAAL was found to be associated with higher risk of postoperative morbidity (p=0.002) and with longer hospital stay (p<0.001). Both preoperative and intraoperative risk factors may be responsible for PAAL after pulmonary lobectomy. VATS does not appear to prevent this postoperative complication. An alveolar air leak lasting beyond 5 days after pulmonary lobectomy is associated with worse postoperative outcomes.

MOG-IgG positive optic neuritis after SARS-CoV-2 infection.

BACKGROUND: Many neurologic complications have been described after severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) including atypical cases of optic neuritis (ON), positive to myelin oligodendrocyte glycoprotein (MOG) IgG. OBJECTIVE: To report a case of MOG-IgG-associated ON and discuss why SARS-CoV-2 infection could be a potential trigger. METHODS: Retrospective single case report. RESULTS: We report a case of ON with positive MOG-IgG developed 15 days after presentation of SARS-CoV-2 infection. CONCLUSION: This report suggests that SARS-CoV-2 infection may have triggered autoantibodies production against MOG leading to ON.

Post-Intubation Tracheoesophageal Fistula: Surgical Management by Complete Cervical Tracheal Transection.

We report successful surgical management of post-intubation tracheoesophageal fistula (TEF) in an adult patient requiring long-term mechanical ventilation. A complete tracheal transection without tracheal resection, via an anterior cervical approach, followed by direct closure of tracheal and esophageal defect, and interposition of muscle flap between the suture lines and tracheal reconstruction was performed. In selected cases, this surgical procedure may be a viable alternative to traditional techniques used to treat post-intubation TEF via the anterior or lateral cervical approach.

Acquired Benign Tracheoesophageal Fistula: An Alternative Tracheoplastic Technique.

We present a case of surgical management of a tracheoesophageal fistula (TEF) following prolonged intubation. After transverse tracheal division and retraction of the distal stump, direct closure of the esophageal defect and repair of the membranous tracheal defect using a synthetic bioabsorbable patch were performed, followed by interposition of muscle flap between the suture lines and tracheal reconstruction. Large TEFs, without tracheal stenosis or circumferential airway defect, associated with marked peritracheal inflammation, may be treated with this alternative tracheoplastic technique in patients deemed not suitable for tracheal resection and anastomosis.

Choroidal Changes in Blood Flow in Patients with Intermediate AMD after Oral Dietary Supplement Based on Astaxanthin, Bromelain, Vitamin D3, Folic Acid, Lutein, and Antioxidants.

Background and Objectives: The aim of this study was to investigate the impact of oral administration of the combination of astaxanthin (AXT), lutein, folic acid, vitamin D3, and bromelain with antioxidants on choroidal blood flow in patients with age-related intermediate macular degeneration (AMD). Materials and Methods: Patients affected by intermediate AMD and treated with daily oral nutritional supplement with AXT, bromelain, vitamin D3, folic acid, lutein, and antioxidants for a period of at least 6 months were included in this retrospective study. A control group homogenous for age and sex was also included in the analysis. All participants underwent a complete ophthalmologic examination, spectral domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCTA) evaluation. Outcome measures were choroidal thickness (CHT) and choriocapillary vessel density (CCVD) after six months of AXT assumption. Results: CCVD values showed statistically significant difference between cases and controls at baseline (p < 0.001) and in the cases during follow-up (p < 0.001). The CHT measurements showed statistically significant difference between cases and controls (p = 0.002) and in the cases during follow-up (p < 0.001). Conclusions: The combined use of structural OCT and OCTA allows for a detailed analysis in vivo of perfusion parameters of the choriocapillaris and choroid and evaluation of changes of choroidal blood flow after oral nutritional supplements that affect blood flow velocity.

Autologous Iris transplant as plug for macular hole retinal detachment in highly myopic eyes.

PURPOSE: To describe the anatomic and visual outcomes of eyes undergoing autologous iris transplantation for macular hole retinal detachment. METHODS: Seven consecutive patients with macular hole retinal detachment were enrolled in a single-arm prospective study. All patients underwent pars plana vitrectomy with autologous iris transplantation placed in the subretinal space as a plug to close the macular hole; in one case, a posterior retinal break was also closed with the same technique. RESULTS: Seven patients (2 males and 5 females) with a mean age of 69.14 ± 7.79 years (range 58-80 years) were followed up for a period of six months. The best-corrected visual acuity improved from 2.44 ± 0.48 logMAR (20/2000) preoperatively to 1.90 ± 0.26 logMAR (20/800) 6 months after surgery. Optical coherence tomography analysis showed retinal adhesion around the iris plug, and the retina remained dry in the follow-up period. CONCLUSIONS: In this series of macular hole retinal detachments, autologous iris transplantation placed as a plug over the retinal pigment epithelium facing the macular hole opening or directly over the bare sclera achieved anatomical success with improvement in visual function.

Italian survey on non-intubated thoracic surgery: results from INFINITY group.

BACKGROUND: Non-Intubated Thoracic Surgery (NITS) is becoming increasingly adopted all over the world. Although it is mainly used for pleural operations,, non-intubated parenchymal lung surgery has been less frequently reported. Recently, NITS utilization seems to be increased also in Italy, albeit there are no multi-center studies confirming this finding. The objective of this survey is to assess quantitatively and qualitatively the performance of NITS in Italy. METHODS: In 2018 a web-based national survey on Non-Intubated management including both thoracic surgeons and anesthesiologists was carried out. Reference centers have been asked to answer 32 questions. Replies were collected from June 26 to November 31, 2019. RESULTS: We raised feedbacks from 95% (55/58) of Italian centers. Seventy-eight percent of the respondents perform NITS but only 38% of them used this strategy for parenchymal surgery. These procedures are more frequently carried out in patients with severe comorbidities and/or with poor lung function. Several issues as obesity, previous non-invasive ventilation and/or oxygen therapy are considered contraindications to NITS. The regional anesthesia technique most used to provide intra- and postoperative analgesia was the paravertebral block (37%). Conversion to general anesthesia is not anecdotal (31% of answerers). More than half of the centers believed that NITS may reduce postoperative intensive care unit admissions. Approximately a quarter of the centers are conducting trials on NITS and, three quarters of the respondent suppose that the number of these procedures will increase in the future. CONCLUSIONS: There is a growing interest in Italy for NITS and this survey provides a clear view of the national management framework of these procedures.

Timing of surgery and elective perioperative management of patients with previous SARS-CoV-2 infection: a SIAARTI expert consensus statement.

BACKGROUND: The appropriate timing of surgery and perioperative management of patients with previous SARS-CoV-2 infection are open issues. The purpose of this document is to support the clinical decision-making process regarding the patient with previous Sars-CoV-2 infection to undergo elective surgery. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient's surgical process. METHODS: The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) selected 11 experts to reach a consensus on key aspects of this theme in adult and pediatric population. The methods of this process document were in accordance to the principles of rapid review of the scientific literature and modified Delphi method. The experts produced statements and supporting reasons in the form of an informative text. The overall list of statements was subjected to a vote in order to express the degree of consent. RESULTS: Patients should not undergo elective surgery within 7 weeks of infection unless there is the risk of a negative evolution of the disease. To mitigate the risk of postsurgical mortality, a multidisciplinary approach seemed useful in addition to the use of validated algorithms to estimate the risk of perioperative morbidity and mortality; the risk related to SARS-CoV-2 infection should be added. The risk of potential nosocomial contagion from a positive patients should also be considered when deciding to proceed with surgery. Most of the evidence came from previous SARS-CoV-2 variants, so the evidence should be considered indirect. CONCLUSION: A balanced preoperative multidisciplinary risk-benefit evaluation is needed in patients with previous infection by SARS-CoV-2 for elective surgery.

Airway management for one lung ventilation during COVID-19 pandemic: a survey within Italian anesthesiologists.

BACKGROUND: Airway management for thoracic surgery represents a high risk setting for SARS-CoV-2 infection diffusion due to complex and invasive airway instrumentation and techniques. RESULTS: An 18-item questionnaire was submitted to the 56 members of the Thoracic subcommittee of the SIAARTI Cardio-Thoraco-Vascular Research Group to provide a snapshot of current situation and national variability of devices and procedures for airway management during the COVID-19 pandemic. The response rate was 64%. Eighty-three percent of anesthetists declared that they modified their airway management strategies. The Hospital Management considered necessary to provide a complete level 3 personal protective equipment for thoracic anesthetists only in 47% of cases. Double-lumen tube and bronchial blocker were preferred by 53% and 22% of responders to achieve one-lung ventilation respectively. Over 90% of responders considered the videolaryngoscope with separate screen and rapid sequence induction/intubation useful to minimize the infection risk. Thirty-nine percent of participants considered mandatory the bronchoscopic check of airway devices. Vivasight-DL was considered comfortable by more than 50% of responders while protective box and plastic drape were judged as uncomfortable by most of anesthetists. CONCLUSIONS: The survey reveals many changes in the clinical practice due to SARS-CoV-2 outbreak. A certain diffusion of new devices such as the VivaSight-DL and barrier enclosure systems emerged too. Finally, we found that most of Italian hospitals did not recognize thoracic anesthesia as a high-risk specialty for risk of virus diffusion.

OCTA in macular intraretinal microvascular abnormalities: Retinal vascular density remodeling after panretinal photocoagulation.

PURPOSE: To describe a case of macular intraretinal microvascular abnormality (IRMA) detected with Optical Coherence Tomography Angiography (OCTA) and to show its remodeling and vascular density changes after panretinal photocoagulation (PRP) during an 18-month follow-up. METHODS: Case report. RESULTS: A 22-year-old female patient with proliferative diabetic retinopathy was found to have a small hyperreflective formation with posterior shadow cone and signal flow, located at the temporal margin of the fovea avascular zone (FAZ), identified as macular IRMA with OCTA. Her best-corrected-visual acuity was 20/20. Four months later the macular IRMA was larger and, in its context, there was also an increase in the flow area in B-scan. The patient underwent PRP and after 18 months we observed a regression of macular IRMA and an increase in the superficial capillary plexus vessel density in all sectors in comparison to baseline. CONCLUSION: OCTA is a non-invasive tool that recognize macular IRMA in diabetic retinopathy patient and it could be helpful to follow their qualitative and quantitative vascular evolution over time.

Biomarkers in Early Response to Brolucizumab on Pigment Epithelium Detachment Associated with Exudative Age-Related Macular Degeneration.

BACKGROUND: The purpose of this study was to describe early changes in the morphology of pigment epithelium detachments (PED) after an intravitreal injection of Brolucizumab into eyes with macular neovascularization secondary to exudative age-related macular degeneration (e-AMD). METHOD: We included twelve eyes of 12 patients with PED secondary to e-AMD which were not responding to prior anti-VEGF treatments. An ophthalmic examination and an assessment of PED-horizontal maximal diameter (PED-HMD), PED-maximum high (PED-MH) and macular neovascularization (MNV) flow area (MNV-FA) by the means of structural optical coherence tomography (OCT) and OCT Angiography (OCT-A) were performed at baseline, as well as 1, 7, 14 and 30 days after the injection. RESULTS: The mean age of the population of study was 78.4 (SD ± 4.8). The mean number of previous Ranibizumab or Aflibercept injections was 13 (SD ± 8). At the last follow-up visit, the PED-HMD did not significantly change (p = 0.16; F(DF:1.94, 20,85) = 1.9), the PED-MH showed a significant reduction [p = 0.01; F(DF:1.31, 14.13) = 6.84.] and the MNV-FA did not significantly differ (p = 0.1; F(1.97, 21.67) = 2.54) from baseline. No signs of ocular inflammation were observed during follow-up. CONCLUSIONS: A single Brolucizumab injection was able to determine the short-term effects on PEDs' anatomical features of eyes with an unresponsive e-AMD.

Chronic Chest Pain Control after Trans-Thoracic Biopsy in Mediastinal Lymphomas.

Chest pain following a trans-thoracic biopsy often has multiple etiologies, especially in patients with lymphomas. Pathological neuronal mechanisms integrate with an overproduction of IL-6, TNF-α, IL1-ß by macrophages and monocytes, which amplifies inflammation and pain. In consideration of this complex pathogenesis, international guidelines recommend diversified analgesia protocols: thoracic epidural, paravertebral block, and systemic administration of opioids. This study reports an attempt to reduce chest pain and prevent chronic pain in 51 patients undergoing trans-thoracic biopsy for mediastinal lymphoma. The entity of pain, measured 72nd hour after biopsy by the Numerical Rating Scale (NRS), was compared with that seen at a 6th month checkpoint in 46 patients. The pain decreased in all cases. At the 6th month checkpoint, among 31 opioid-treated patients, none of the 16 patients with NRS < 6 within the 72nd hour post biopsy had developed chronic chest pain, while 8 of the 15 with higher values did (p < 0.01). Of 10 patients undergoing thoracotomy and treated with opioids, eight had a NRS of no more than 2, of which six had no chronic pain. Of the twenty-one patients who underwent VATS biopsy and were treated with opioids, fifteen had NRS no greater than 2, of which ten had no chronic pain. Subgroups of patients biopsied under mediastinotomy or video-assisted thoracoscopic surgery (VATS) and treated with thoracic epidural analgesia (TEA) or PVB were too small for such analysis.

Variations in the branching patterns of pulmonary artery during thoracoscopic pulmonary resection.

PURPOSE: The knowledge of variations in the branching patterns of pulmonary artery may have important clinical implications in the field of thoracic surgery. METHODS: At the Department of Thoracic Surgery of Monaldi Hospital in Naples, between January 2017 and December 2019, 569 anatomic pulmonary resections via video-assisted thoracic surgery, including lobectomy and segmentectomy, were performed. RESULTS: Among the 569 thoracoscopic pulmonary resections, 24 variations in the branching patterns of pulmonary artery were identified and documented. Anatomic variations on the left were more frequent than on the right. CONCLUSION: This paper, providing a summary of vascular anomalies identified during major lung resections, could help surgeons avoid intraoperative complications, especially during minimally invasive procedures where the visual field is more restricted than open surgery.

THE INCIDENCE OF NEOVASCULARIZATION IN CENTRAL SEROUS CHORIORETINOPATHY BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: To evaluate the incidence of neovascularization (NV) secondary to central serous chorioretinopathy (CSC)-a condition belonging to the spectrum of pachychoroid disorders by means of optical coherence tomography angiography. METHODS: One hundred and seventy five eyes with CSC were evaluated in this retrospective observational study. The eyes with acute or chronic CSC with no NV were included in Group 1, and those with NV were evaluated in Group 2. Only eyes that had undergone structural optical coherence tomography and optical coherence tomography angiography were included. Age, best-corrected visual acuity, and subfoveal choroidal thickness were evaluated in all eyes. In Group 2, the type and morphology of NV and the occurrence of exudation were considered. RESULTS: Of a total of 175 eyes with CSC, 86 had the acute form and 89 the chronic. Approximately 140 belonged to Group 1 (80%) and 35 to Group 2 (20%). Approximately 39.2% of all patient with chronic CSC developed NV. Mean age in Groups 1 and 2 was 53.3 years (±10.9) and 66.6 years (±10.2), respectively. Mean best-corrected visual acuity in Groups 1 and 2 was 45.7 (±11.7) and 30.9 (±17.9) early treatment diabetic retinopathy study letters, respectively. Mean CCT in Group 1 and 2 was 417.5 µm (±123) and 344.2 µm (±165.9), respectively. In Group 2, all patients had Type 1 NV (100%); 29 eyes (83%) had filamentous feature, and 6 eyes (17%) had irregular shape. Silent nonexudative NV was observed in 7 eyes (20%), all belonging to Group 2. CONCLUSION: The use of optical coherence tomography angiography in everyday clinical practice allows for the accurate analysis of the chorioretinal vascular setting, with the identification of new vessels that could remain misdiagnosed.