Non-invasive monitoring of cyclodialysis cleft using anterior segment optical coherence tomography and its role in informing clinical treatment decisions.

PURPOSE: Anterior segment optical coherence tomography (AS-OCT) is an emerging imaging modality with an expanding role in glaucoma diagnosis and management. We present a series of two cases of iatrogenic cyclodialysis cleft and their conservative management being directly informed by non-invasive AS-OCT monitoring. OBSERVATIONS: Retrospective case series. A 51 year-old male and a 29 year-old male each underwent gonioscopy-assisted transluminal trabeculotomy for uncontrolled glaucoma with a cyclodialysis cleft being diagnosed postoperatively and then monitored using serial AS-OCT images. In both cases, conservative medical management was initially employed. Worsening hypotony maculopathy and decreasing best corrected visual acuity were evident in both cases at times when gonioscopy yielded inadequate visualization to meaningfully inform treatment decisions. Escalation to more invasive therapies was therefore considered. AS-OCT imaging revealed consistent anatomical improvement at each follow-up and ultimately both clefts closed without treatment escalation. CONCLUSIONS AND IMPORTANCE: AS-OCT played a critical role in the diagnosis and directly informed the conservative management of both of these cases. This non-invasive imaging modality may allow for deferral of invasive treatment escalation in some cases of cyclodialysis cleft.

Diagnosis and Treatment of Primary Headache Disorders in Older Adults.

OBJECTIVES: To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature. DESIGN: Review of the most current and relevant headache literature for practitioners specializing in geriatric care. RESULTS: Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging. CONCLUSION: The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.

Visual and Refractive Outcomes in Manual versus Femtosecond Laser-Assisted Cataract Surgery: A Single-Center Retrospective Cohort Analysis of 1838 Eyes.

PURPOSE: Femtosecond laser-assisted cataract surgery (FLACS) has emerged as an alternative to manual cataract surgery (MCS) for corneal incision and capsulorhexis creation, as well as nuclear fragmentation. This study compares postoperative refractive and visual outcomes in eyes receiving MCS or FLACS. DESIGN: Single-center, comparative, retrospective cohort analysis. PARTICIPANTS: Consecutive eyes receiving FLACS and MCS from July 1, 2012, to July 31, 2015, at a single tertiary care center. METHODS: Demographic data, ocular history, preoperative measurements and biometry, and postoperative surgical results were retrospectively obtained and statistically analyzed using a generalized linear mixed model adjusting for differences in baseline characteristics and within-patient correlation. A 2-tailed P value <0.05 was considered statistically significant throughout the study. MAIN OUTCOME MEASURES: Percentage of eyes achieving absolute error (AE) ≤0.5 diopters (D). Secondary outcomes included percentage of eyes with AE ≤0.25 D and ≤1.0 D, and percentage of distance-targeted eyes achieving uncorrected distance visual acuity (UDVA) of 20/20 or better, 20/25 or better, and 20/30 or better. RESULTS: A total of 883 eyes received MCS and 955 received FLACS among 1089 patients. Some 82.6% of FLACS eyes and 78.8% of MCS eyes had ≤0.5 D of AE at 3 weeks, representing an adjusted odds ratio (OR) of 1.28 (95% confidence interval [CI], 0.98-1.66) of FLACS relative to MCS being within target. Some 97.1% of FLACS and 97.2% of MCS eyes had ≤1.0 D of AE (OR, 0.96; 95% CI, 0.57-1.60) and 49.3% of FLACS and 46.3% of MCS eyes, ≤0.25 D of AE (OR, 1.13; 95% CI, 0.91-1.39). Factors predictive of a favorable refractive outcome included axial length between 22 and 24.8 mm, receiving a toric intraocular lens, less preoperative cylinder, and greater preoperative average keratometry. There was no significant difference in the percentage of patients targeted for distance who achieved UDVA of 20/20 or better (P = 0.30), 20/25 or better (P = 0.06), or 20/30 or better (P = 0.66) vision. CONCLUSIONS: Postoperatively, there was no statistically significant difference found between eyes undergoing FLACS and eyes undergoing MCS with respect to refractive and visual outcomes.

Prospective Comparative Analysis of 4 Different Intraocular Pressure Measurement Techniques and Their Effects on Pressure Readings.

PURPOSE: To compare intraocular pressure (IOP) measurement using the Goldmann applanation tonometry (GAT) without fluorescein, with fluorescein strips, with fluorescein droplets, and IOP measurement with Tono-Pen Avia (TPA). PATIENTS AND METHODS: This was a prospective comparative clinical analysis. It was performed in clinical practice. The study population consisted of 40 volunteer patients, 1 eye per patient. All patients who were 18 years and older having routine ophthalmological examination were eligible to participate. Active corneal abrasions and/or ulcers, previous glaucoma surgery, or prostheses interfering with GAT measurement were excluded. GAT IOP was measured first without fluorescein, then with fluorescein strip, then with fluorescein droplet, and finally with the TPA device. The main outcome measure was central corneal IOP. RESULTS: Mean±SD IOP measurements for GAT without fluorescein, with fluorescein strip, with fluorescein droplet, and for TPA groups were 12.65±3.01, 14.70±2.82, 15.78±2.64, and 16.33±3.08 mm Hg, respectively. Repeated-measures analysis of variance corrected with the Greenhouse-Geisser estimate ([Latin Small Letter Open E]=0.732) showed that measuring technique had a significant effect on IOP measurements (F2.20,85.59=34.66, P<0.001). The pairwise post hoc testing showed statistically significant mean differences (P≤0.001) between all techniques except when GAT with fluorescein droplet was compared with TPA (P=0.222). The Bland-Altman analyses showed 95% limits of agreement maximum potential discrepancies in measurement ranging from 5.89 mm Hg in the GAT with fluorescein strip versus droplet compared with 11.83 mm Hg in the GAT with fluorescein strip versus TPA comparison. CONCLUSIONS: IOP measurement technique significantly impacted the values obtained. The ophthalmologist should ensure consistent measurement technique to minimize variability when following patients.

Distal coronary embolization following acute myocardial infarction increases early infarct size and late left ventricular wall thinning in a porcine model.

BACKGROUND: Distal coronary embolization (DCE) of thrombotic material occurs frequently during percutaneous interventions for acute myocardial infarction and can alter coronary flow grades. The significance of DCE on infarct size and myocardial function remains unsettled. The aims of this study were to evaluate the effects of DCE sufficient to cause no-reflow on infarct size, cardiac function and ventricular remodeling in a porcine acute myocardial infarction model. METHODS AND RESULTS: Female Yorkshire pigs underwent 60 min balloon occlusion of the left anterior descending coronary artery followed by reperfusion and injection of either microthrombi (prepared from autologous porcine blood) sufficient to cause no-reflow (DCE), or saline (control). Animals were sacrificed at 3 h (n = 5), 3 days (n = 20) or 6 weeks (n = 20) post-AMI. Cardiovascular magnetic resonance (CMR), serum troponin-I, and cardiac gelatinase (MMP) and survival kinase (Akt) activities were assessed. At 3d, DCE increased infarct size (CMR: 18.8% vs. 14.5%, p = 0.04; serum troponin-I: 13.3 vs. 6.9 ng/uL, p < 0.05) and MMP-2 activity levels (0.81 vs. 0.49, p = 0.002), with reduced activation of Akt (0.06 versus 0.26, p = 0.02). At 6 weeks, there were no differences in infarct size, ventricular volume or ejection fraction between the two groups, although infarct transmurality (70% vs. 57%, p< 0.04) and ventricular thinning (percent change in mid anteroseptal wall thickness:-25.6% vs. 0.7%, p = 0.03) were significantly increased in the DCE group. CONCLUSIONS: DCE increased early infarct size, but without affecting later infarct size, cardiac function or ventricular volumes. The significance of the later remodelling changes (ventricular thinning and transmurality) following DCE, possibly due to changes in MMP-2 activity and Akt activation, merits further study.

Electron microscopic evaluation of a gold glaucoma micro shunt after explantation.

UNLABELLED: We present a case of an explanted gold glaucoma micro shunt (GMS Plus) and the subsequent light and electron microscopic analyses. The shunt was implanted in a patient with medically refractive glaucoma. The intraocular pressure (IOP) was stable at 12 mm Hg 6 months postoperatively but spiked to 26 mm Hg 6 months later; membranous growth was visible on the implant gonioscopically. A second gold micro shunt was placed 2 years after the first. The IOP was 7 mm Hg 1 week postoperatively but increased to 23 mm Hg 3 weeks later; similar membranous growth was visible on this implant. One of the shunts was explanted, and light and scanning electron microscopic analyses revealed encapsulation around the shunt exterior and connective tissue invasion of the microstructure. This represents the first electron microscopic analysis of an explanted gold glaucoma micro shunt and the first unequivocal images of the fibrotic pseudo-capsule traversing its microchannels and fenestrations. FINANCIAL DISCLOSURE: Dr. Ahmed is a consultant to and has received research grants from Solx, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Unexpected calcification after direct intravascular injection of autologous bone marrow-derived cells in a chronic total occlusion model.

AIMS: Patients with symptomatic chronic total occlusions (CTO) remain a therapeutic challenge. Enhancement of intraluminal neovascularisation by pro-angiogenic therapies has been proposed as a new strategy to improve percutaneous revascularisation. The aim of this study was to investigate the effects of intraluminal injection of bone marrow-derived cells (BMC) into experimental CTO. METHODS AND RESULTS: CTO were created in the femoral arteries of 43 New Zealand White rabbits using the thrombin injection model. At 12 weeks following CTO creation, 33 rabbits were injected with either cultured BMC (n=19) or control DMEM alone (n=14) directly into the CTO. Ten rabbits were used for cell tracking (seven BMC and three control). BMC labelled with fluorescent Qdot® nanocrystals were identified in the CTO up to one week after injection. Animals were sacrificed at three to five weeks post-treatment and arterial samples were excised for micro-CT imaging and histologic morphometric analysis. There was a significant but modest increase in neovascularisation in BMC-treated arteries compared to controls (7.47±4.75% vs. 4.35±2.97%, p<0.05). However, unexpected intravascular calcification was only detected within the CTO in BMC cell treated arteries. Western blot for conditioned medium from BMC showed up-regulation of osteogenic proteins (BMP-2 and -7). CONCLUSIONS: Although direct delivery of BMC into CTO increases neovascularisation, undesirable vascular calcification will limit this therapeutic approach.

A review of the diagnosis and treatment of rosacea.

Rosacea is a common chronic inflammatory disease of the skin and is associated with a number of etiological causes and inciting factors. It is characterized by erythematous changes of the facial skin, and commonly presents with papules, pustules, or telangiectasias. The 4 subtypes of rosacea are categorized according to secondary symptoms, such as pain, erythema, dryness, and edema. A number of therapies are available to treat rosacea, some of which can be used in combination. The mainstays of therapy are topical metronidazole, topical azelaic acid, and oral tetracyclines. Other pharmacotherapeutic interventions have been shown to improve the signs and symptoms of rosacea, although many of these have not yet received approval by the US Food and Drug Administration for this indication.

A case of hermansky-pudlak syndrome with pulmonary sarcoidosis.

Hermansky-Pudlak syndrome is an autosomal recessive disorder of lysosomal storage characterized by the triad of occulocutaneous albinism, bleeding diathesis, and pulmonary fibrosis. Sarcoidosis is a disease characterized by the development of noncaseating granulomas, most commonly affecting the lungs. The pathophysiology, histological findings, clinical symptoms, and treatment of the pulmonary manifestations of Hermansky-Pudlak syndrome are distinct from those of sarcoidosis. As patients with occulocutaneous and bleeding manifestations of Hermansky-Pudlak syndrome may also develop pulmonary fibrosis, the authors present this case to illustrate that pulmonary symptoms must be carefully evaluated in those with this syndrome because in this case, the patient developed underlying pulmonary sarcoidosis. To the authors' knowledge, this is the first documented case of Hermansky-Pudlak syndrome with concomitant pulmonary sarcoidosis.

Numerical study of hemodynamics and wall mechanics in distal end-to-side anastomoses of bypass grafts.

The development and progress of distal anastomotic intimal hyperplasia seems to be promoted by altered flow conditions and intramural stress distributions at the region of the artery-graft junction of vascular bypass configurations. From clinical observations, it is known that intimal hyperplasia preferentially occurs at outflow anastomoses of prosthetic bypass grafts. In order to gain a deeper insight into post-operative disease processes, and subsequently, to contribute to the development of improved vascular reconstructions with respect to long term patency rates, detailed studies are required. In context with in vivo experiments, this study was designed to analyze the flow dynamics and wall mechanics in anatomically correct bypass configurations related to two different surgical techniques and resulting geometries (conventional geometry and Miller-cuff). The influence of geometric conditions and of different compliance of synthetic graft, the host artery and the interposed venous cuff on the hemodynamic behavior and on the wall stresses are investigated. The flow studies apply the time-dependent, three-dimensional Navier-Stokes equations describing the motion of an incompressible Newtonian fluid. The vessel walls are described by a geometrically non-linear shell structure. In an iterative coupling procedure, the two problems are solved by means of the finite element method. The numerical results demonstrate non-physiological flow patterns in the anastomotic region. Strongly skewed axial velocity profiles and high secondary velocities occur downstream the artery-graft junction. On the artery floor opposite the junction, flow separation and zones of recirculation are found. The wall mechanical studies show that increased compliance mismatch leads to increased intramural stresses, and thus, may have a proliferative influence on suture line hyperplasia, as it is observed in the in vivo study.