Altered Blood Flow in the Ophthalmic and Internal Carotid Arteries in Patients with Age-Related Macular Degeneration Measured Using Noncontrast MR Angiography at 7T.

BACKGROUND AND PURPOSE: Age-related macular degeneration is associated with reduced perfusion of the eye; however, the role of altered blood flow in the upstream ophthalmic or internal carotid arteries is unclear. We used ultra-high-field MR imaging to investigate whether the diameter of and blood flow in the ophthalmic artery and/or the ICA are altered in age-related macular degeneration and whether any blood flow changes are associated with disease progression. MATERIALS AND METHODS: Twenty-four patients with age-related macular degeneration and 13 similarly-aged healthy controls participated. TOF and high-resolution dynamic 2D phase-contrast MRA (0.26 × 0.26 × 2mm3, 100-ms effective sampling rate) was acquired at 7T. Vessel diameters were calculated from cross-sectional areas in phase-contrast acquisitions. Blood flow time-series were measured across the cardiac cycle. RESULTS: The ophthalmic artery vessel diameter was found to be significantly smaller in patients with age-related macular degeneration than in controls. Volumetric flow through the ophthalmic artery was significantly lower in patients with late age-related macular degeneration, with a significant trend of decreasing volumetric ophthalmic artery flow rates with increasing disease severity. The resistance index was significantly greater in patients with age-related macular degeneration than in controls in the ophthalmic artery. Flow velocity through the ophthalmic artery and ICA was significantly higher in patients with age-related macular degeneration. Ophthalmic artery blood flow as a percentage of ipsilateral ICA blood flow was nearly double in controls than in patients with age-related macular degeneration. CONCLUSIONS: These findings support the hypothesis that vascular changes upstream to the eye are associated with the severity of age-related macular degeneration. Additional investigation into the potential causality of this relationship and whether treatments that improve ocular circulation slow disease progression is warranted.

Ocular injuries and diseases at a combat support hospital in support of Operations Desert Shield and Desert Storm.

A retrospective review of all emergency department visits to a combat support hospital (one of four combining to support 150,000 troops) during Operations Desert Shield and Desert Storm was conducted, and all medical records of patients with ocular complaints were analyzed. Ocular injury and/or disease accounted for 14% (108/767) of these visits to the emergency department. Of 108 patients with ocular complaints, corneal foreign bodies (18), ocular burns (14), and traumatic iritis (eight) were the most common injuries treated, while blepharitis and conjunctivitis (16) were the most common diseases. Nineteen (18%) of the 108 patients with ocular complaints were treated during support of the ground war in Iraq (13 were Iraqi prisoners). Ophthalmic injuries accounted for 13% (19/149) of all ground war casualties; however, eight individuals had associated injuries deemed more significant than those of ocular concern. This incidence continues the trend of earlier wars, which has demonstrated a steady increase in ocular injuries. Most US Army troops were issued protective goggles, but only three of 92 American patients wore them at the time of their injury and/or disease.

Screening for ocular toxicity in asymptomatic patients treated with tamoxifen.

Tamoxifen is an antiestrogen drug used in the treatment of patients with breast cancer that is being studied for use in patients at high risk for developing breast cancer. Case reports have documented ocular toxicity caused by tamoxifen in patients with visual symptoms. We attempted to determine the prevalence of ocular toxicity in visually asymptomatic tamoxifen-treated patients. We performed extensive ocular examinations on 135 visually asymptomatic tamoxifen-treated patients. Two patients (1.5%) had intraretinal refractile crystals consistent with tamoxifen retinopathy. Both patients were without visual symptoms or visual loss. Corneal crystals, macular edema, and optic nerve changes were absent. The cumulative tamoxifen doses of these two patients were 10.9 and 21.9 g, respectively. For the 135 patients studied, the mean cumulative dose was 17.2 g, with a standard deviation of 13.0. We do not believe the relatively uncommon finding of tamoxifen-related ocular toxicity merits special screening for such disease.

The inpatient experience of a U.S. Army combat support hospital in the Persian Gulf during non-combat and combat periods.

To identify the key factors that control the workload of a U.S. military hospital during deployment, we studied all 574 admissions to the 46th Combat Support Hospital (CSH) during its deployment during Operations Desert Shield and Desert Storm. Date of admission, admission diagnosis, admitting service, length of hospitalization, disposition, nationality, and sex for each admission were analyzed. The workload of the 46th CSH varied markedly during the different periods of its deployment. Three hundred seventy-eight (66%) of the 574 admissions occurred during Operation Desert Shield, although admissions occurred at the greatest rate during the short Ground War phase of Operation Desert Storm. Iraqis accounted for 82% of the admissions during the Ground War and 51% of the total Desert Storm admissions. The most important factors determining the workload of the 46th CSH were the combat situation, effectiveness of the air-evacuation system, and the obligation to treat enemy soldiers and civilians.

Medical care of Iraqis at a forwardly deployed U.S. Army hospital during Operation Desert Storm.

To evaluate the injuries and diseases and their subsequent care for both Iraqis and U.S. soldiers in the Persian Gulf War, we analyzed all 196 admissions to the 46th Combat Support Hospital during Operation Desert Storm, with primary focus on the 118 admissions during the Ground War. Admission diagnosis was used to classify injury or disease. Percentage of patients who underwent surgery for combat wounds and percentage of patients who were air-evacuated were used as measurements of quality of care. The proportion of Iraqi patients who had been wounded in action was significantly higher than the proportion for Americans (95 vs. 53% for the Ground War). The rate of surgical procedures per wounded patients admitted was the same for Iraqis (28%) as for Americans (27%). Rates of air-evacuation for Iraqis were not statistically different from those for Americans in the same category of admission diagnoses. These last two findings suggest that the quality of care given to Iraqis was the same as that given to Americans.

Control of intraocular inflammation associated with cataract surgery.

Major advances in cataract extraction techniques and instrumentation have occurred over the past decade. Smaller incisions, more efficient phacoemulsifiers, and decreased surgical times are a few of the changes that have helped to alleviate postoperative inflammation, but postoperative inflammation continues to be a cause of patient discomfort; delayed recovery; and, in some cases, suboptimal visual results secondary to cystoid macular edema. This article reviews the most recent literature regarding the control of intraocular inflammation associated with cataract surgery.

Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema.

OBJECTIVE: To evaluate the efficacy of ketorolac tromethamine 0.5% ophthalmic solution, prednisolone acetate 1.0% ophthalmic solution, and ketorolac and prednisolone combination therapy in the treatment of acute, visually significant, cystoid macular edema (CME) occurring after cataract extraction surgery. DESIGN: Randomized, double-masked, prospective trial. PARTICIPANTS: Twenty-eight patients who had undergone cataract extraction and in whom clinical CME developed within 21 to 90 days after cataract surgery. METHODS: Patients were randomized to topical therapy with ketorolac (group K), prednisolone (group P), or ketorolac and prednisolone combination therapy (group C) four times daily. Treatment was continued until CME resolved or for 3 months, whichever occurred first. Treatment was then tapered over 3 weeks. Examinations were monthly and included Snellen visual acuity, contrast sensitivity, Amsler grid, slit-lamp examination, dilated fundus examination, and fluorescein angiography. RESULTS: Twenty-six of 28 patients completed the study. Patients were enrolled an average of 48 days after surgery. The average improvements in Snellen visual acuity were as follows: 1.6 lines in group K, 1.1 lines in group P, and 3.8 lines in group C. This reached statistical significance for all visits when group C was compared with group P, and for visits 4 and 5 when group C was compared with group K. Group C reached a mean change of two lines or more by visit 2; at no time did either group K or P reach a mean two-line improvement. At no time was a significant difference detected between group K and P with regard to visual acuity or change from baseline. A two-line or more improvement in Snellen acuity was achieved in 16 of 26 patients (61%). Analysis by group revealed four of eight patients (50%) in group P, six of nine patients (67%) in group K, and eight of nine patients (89%) in group C who had achieved a two-line or more improvement. In patients who did improve two lines or more, improvement occurred an average of 2.75 months after initiating therapy in group P, 1.43 months in group K, and 1.33 months in group C. Improvements in contrast sensitivity and leakage on fluorescein angiography tended to mirror improvements in Snellen acuity. CONCLUSIONS: Treatment of acute, visually significant pseudophakic CME with ketorolac and prednisolone combination therapy appears to offer benefits over monotherapy with either agent alone. Patients were more likely to experience recovery of two lines or more of visual acuity. Patients treated with combination therapy or ketorolac monotherapy responded more quickly than did patients treated with prednisolone alone.

Wound strength comparison of a 5.1-millimeter no-stitch with a 7.0-millimeter sutured incision in human cadaver globes.

We compared the wound strength of 5.1-millimeter no-stitch incisions with that of 7.0-millimeter sutured incisions in cadaver eyes. Each incision was performed on seven cadaver eyes. Wound integrity was evaluated by subjecting each globe to increasing intraocular pressure (IOP), increasing external pressure, and sudden external pressure. Wound leaks occurred in the 7.0-millimeter-incision globes at consistently lower IOPs and with less external pressure than they did in the 5.1-millimeter-incision globes. We conclude that the 5.1-millimeter no-stitch flap incision has greater wound integrity than the 7.0-millimeter sutured incision when subjected to either internal or external pressures.

Visual and surgical outcomes of retinal detachment following macular hole repair.

OBJECTIVE: To characterize 20 cases of retinal detachment (RD) following surgical repair of macular holes. METHODS: Retrospective review of 20 eyes in 16 patients (4 patients [25%] had bilateral macular hole repairs with subsequent RD) who developed RD in the same eye in which surgical repair of a macular hole had been performed. RESULTS: Twenty detachments in 16 patients were reviewed. The average duration between macular hole repair and presentation of RD was 5.5 weeks. The inferior retina was involved more frequently than the superior retina. A total of 76% of all breaks were located inferiorly. Ten of the 20 eyes were asymptomatic at the time the detachment was diagnosed. Of the 20 eyes, 19 underwent surgical repair, all with anatomic reattachment. At final follow-up, the macular hole was closed in all 20 eyes, and 60% of the patients had final visual acuity improved by 2 lines or more over that before their macular hole repair. CONCLUSION: Retinal detachment is a complication of macular hole surgery. These detachments tend to occur within the first 2 months of follow-up, and have a high success rate of anatomic reattachment with surgery. The occurrence of RD does not preclude improved final visual acuity.

Proptosis as the initial presentation of fungal sinusitis in immunocompetent patients.

BACKGROUND: Fungal sinusitis typically occurs in immunocompromised patients. The authors report four cases of fungal sinusitis in immunocompetent young adults, all of whom had proptosis. METHODS: The diagnosis in all four patients was determined after orbital imaging and sinus biopsies. RESULTS: All four patients required surgical removal of the fungal source and anti-fungal chemotherapy postoperatively. CONCLUSION: Patients with proptosis, ocular pain, or other symptoms suggestive of orbital cellulitis unresponsive to antibiotic treatment should undergo radiographic imaging. If sinus disease is present, biopsy and culture may lead to the diagnosis of fungal disease. Surgical debridement and the appropriate systemic antifungal therapy usually lead to cure.