3-D assessment of gaze-induced eye shape deformations and downgaze-induced vitreous chamber volume increase in highly myopic eyes with staphyloma.

PURPOSE: To determine if the stress of normal eye movements results in gaze-induced globe deformations, vitreous chamber axial length and vitreous chamber axial volume (VCAV) change in highly myopic eyes. METHODS: A prospective imaging study was performed on 82 eyes of 43 patients with high myopia (>27 mm of axial length) with a clinical diagnosis of staphyloma. Three-dimensional MRI scans were acquired while subjects gazed in five directions (primary, nasal, temporal, superior and inferior). Surface renderings were generated, and a processing pipeline was created to automate alignment of the eye and to measure VCAV within 5.5 mm of the visual axis for each eye in every gaze. The degree of gaze-induced globe deformation was determined by calculating the Dice coefficient to assess the degree of overlap of the sclera at each eccentric gaze with that found in primary gaze. Each eccentric gaze VCAV was compared to VCAV in primary gaze using a fixed-effects regression allowing for subject-specific and eye-specific effects. RESULTS: The Dice coefficient showed significant gaze-induced eye shape changes in all gazes (all p<0.0001). There were no statistically significant gaze-induced VCAV changes when comparing primary gaze to nasal, temporal or upgaze. However, when changing from primary to downgaze, VCAV was increased by +4.79 mm3 (p=0.002, 95% CI 1.71 to 7.86). CONCLUSION: Significant gaze-induced globe deformation was noted in all gazes, but a reversible, instantaneous VCAV increase occurred only in downgaze, which is consistent with studies supporting the association of environmental factors such as near work with myopia development and progression.

Burden of eye disease and demand for care in the Bangladesh Rohingya displaced population and host community: A cohort study.

BACKGROUND: There is a growing awareness that addressing chronic as well as acute health conditions may contribute importantly to the well-being of displaced populations, but eye care service has generally not been prioritized in crisis situations. We describe a replicable model of eye care provision as delivered by Orbis International and local partners to the Rohingya and host population in Cox's Bazar, Bangladesh, and characterize the burden of vision impairment and demand for sight-restoring services in this setting. METHODS AND FINDINGS: Orbis International and local secondary facility Cox's Bazar Baitush Sharaf Hospital (CBBSH) provide eye care support to the Rohingya population and the host community of all ages in Cox's Bazar, Bangladesh, with fixed vision screening locations established in Camps 4 and 11 of the Kutupalong refugee settlement. Structured outreach targets these camps and four surrounding local subdistricts, with referrals made as needed for refraction (glasses measurement) and cataract surgery to CBBSH. Between February 2018 and March 2019, 48,105 displaced Rohingya (70.3%, among whom 71.6% were children and 46.5% women) and 20,357 local residents (29.7%, 88.5% children, 54.4% women) underwent vision screening. Displaced Rohingya sought services from a total of 12 surrounding camps, within which coverage was 17.3%, including 43.3% (27,027/62,424) of children aged 5-11 years and 60.0% (5,315/8,857) of adults ≥ 60 years old. The prevalence of blindness (presenting acuity < 3/60) among Rohingya patients exceeded that among local residents by 3- to 6-fold in each 10-year age group between 18 and 59 years (P < 0.001 comparing vision between the two groups in this age range), and the prevalence of cataract requiring surgery was also higher in Rohingya patients (18-29 years: 4.67% versus 1.80%, P = 0.0019; 30-39: 7.61% versus 2.39%, P < 0.001; and 40-49 years: 7.91% versus 3.77%, P = 0.0014). A limitation of the study is lack of data on population prevalence of eye disease. CONCLUSIONS: The burden of untreated eye disease is very high among the Rohingya, particularly those in their peak working years who could contribute most to the resiliency of their community. Demand for eye care service is also great among children and adults in this population with many competing healthcare priorities. Research is needed, building on strong evidence of benefit in settled populations, to explore the specific impact of vision care on the well-being of displaced populations.

Eye-Related Emergency Department Visits and The Opioid Epidemic: a 10-Year Analysis.

PURPOSE: To describe the epidemiology of Emergency Department (ED) visits related to opioid abuse with primary ophthalmic diagnoses in the United States (US). METHODS: This retrospective cross-sectional study used National ED Sample (NEDS) (2006-2015), a representative sample of all US EDs, to analyze and compare the epidemiology of primary ophthalmic diagnoses in opioid abusers and a control group of non-opioid users. National incidence and descriptive statistics were calculated for demographics and prevalent diagnoses. Multivariable logistic regression was used to compare outcomes between primary ophthalmic diagnoses in opioid and non-opioid abusers. RESULTS: An estimated 10,617 visits had a primary ophthalmic diagnosis and an accompanying opioid abuse diagnosis, and the incidence increased from 0.2 in 2006 to 0.6 per 100,000 US population in 2015. Opioid abuse group had more adults (6,747:63.5%) and middle-aged (3,361:31.7%) patients, while in controls adults (7,905,003:40.4%) and children (4,068,534:20.8%) were affected more. Leading etiologies were similar: traumatic and infectious etiologies were most common; however, opioid abuse patients had more severe ophthalmic diagnoses such as orbital fractures (8.4%), orbital cellulitis (7.4%), globe injury (3.4%) and endophthalmitis (3.2%) compared to controls. Patients in the opioid abuse group were also more likely to be admitted (adjusted Odds Ratio [aOR], 28.38 [95% CI, 24.50-32.87]). CONCLUSIONS: In the era of opioid crisis, an increase in ED visits with ophthalmic complaints is seen, with increasing direct and indirect costs on the healthcare system. More research is needed to establish causality and devise strategies to lower this burden.

Risks of ophthalmic disorders in patients with systemic lupus erythematosus - a secondary cohort analysis of population-based claims data.

BACKGROUND: Systemic lupus erythematosus (SLE) can directly affect various part of the ocular system, but there was no comprehensive analysis of ophthalmic disorders of patients with SLE using population-based data. The aim of this study was to investigate the frequency and prevalence of ophthalmic disorders for ophthalmologist visits in adult patients with SLE and to evaluate the risk of dry eye syndrome, cataracts, glaucoma, episcleritis and scleritis, and retinal vascular occlusion in these patients. METHODS: The Taiwan's National Health Insurance Research Database was used to assemble a SLE cohort consisting of newly diagnosed SLE between 2000 and 2012. A comparison cohort was also sampled from the same database and it consisted of 10 patients without SLE for each patient with SLE, based on frequency matching for sex, five-year age interval, and index year. Both cohorts were followed until either the study outcomes have occurred or the end of the follow-up period. RESULTS: Patients with SLE (n = 521) exhibited a significantly higher prevalence (68.1% vs. 60.5%, P = 0.001) and frequency (median 5.51 vs. 1.71 per 10 years, P <  0.001) for outpatient ophthalmologist visits compared with patients without SLE. The risk of dry eye syndrome (adjusted incidence rate ratio [IRR] 4.45, P <  0.001), cataracts (adjusted IRR 3.18, P <  0.001), and glaucoma (adjusted IRR 2.23, P = 0.002) were significantly higher in patients with SLE. In addition, the risk of several SLE related ophthalmic disorders, including episcleritis and scleritis (adjusted IRR 6.11, P <  0.001) and retinal vascular occlusion (adjusted IRR 3.81, P = 0.023) were significantly higher in patients with SLE. CONCLUSIONS: The increased risk of dry eye syndrome, cataracts, glaucoma, episcleritis and scleritis, and retinal vascular occlusion in patients with SLE deserves vigilance.

Ocular Anesthesia-Related Closed Claims from Ophthalmic Mutual Insurance Company 2008-2018.

PURPOSE: To evaluate the types of anesthesia-related closed claims and their contributing factors, using data from the Ophthalmic Mutual Insurance Company (OMIC). DESIGN: Retrospective analysis of preexisting data. PARTICIPANTS: Plaintiffs who filed a professional liability claim or suit (written demand for money) against OMIC-insured ophthalmologists, ophthalmic practices, or surgicenters in which the surgical case occurred. METHODS: Plaintiff claims were collected from the OMIC database from 2008 to 2018 using search queries for terms associated with known complications of ophthalmic anesthesia. MAIN OUTCOME MEASURES: Number and types of anesthesia-related injuries and claims, who administered the anesthesia, the outcomes of the claim or suit, cost to defend, and payments made to plaintiffs. RESULTS: Sixty-three anesthesia-related claims or suits were filed by 50 plaintiffs. Anesthesia-related injuries included globe perforation (n = 17), death (n = 13), retrobulbar hemorrhage (n = 7), optic nerve damage (n = 4), vascular occlusions (n = 2), pain (n = 2), eye or head movement resulting in injury (n = 2), and 1 case each for numbness, diplopia, and tooth loss during intubation. All but 1 patient who died had preexisting, significant comorbidities. Two deaths were related to brainstem anesthesia. Regarding the type of anesthesia in the closed claims, retrobulbar and peribulbar anesthesia were the most common types (n = 16 each), followed by local infiltration around the lids and facial nerve (n = 6), topical anesthesia (n = 5), and general anesthesia (n = 5). In 2 cases, the exact type of anesthesia was unknown but not general. The 5 topical with sedation anesthesia-related claims were due to inadequate pain control (n = 2), ocular movement resulting in capsular rupture (n = 2), or death (n = 1) allegedly related to excessive or inadequate monitoring of sedation. There were 5 claims related to general anesthesia including 4 deaths and 1 tooth loss during intubation. Sedation was alleged to be a factor in 5 cases resulting in death. Anticoagulants were a factor in 3 retrobulbar hemorrhage cases. CONCLUSIONS: Although claims and suits were infrequent given the large number of insured ophthalmologists and the large number of surgical cases requiring various types of anesthesia performed over the 10.5-year study period, severe injuries can occur.

Novel ultrasonographic Halo Score for giant cell arteritis: assessment of diagnostic accuracy and association with ocular ischaemia.

OBJECTIVES: Ultrasound of temporal and axillary arteries may reveal vessel wall inflammation in patients with giant cell arteritis (GCA). We developed a ultrasound scoring system to quantify the extent of vascular inflammation and investigated its diagnostic accuracy and association with clinical factors in GCA. METHODS: This is a prospective study including 89 patients suspected of having GCA, of whom 58 had a confirmed clinical diagnosis of GCA after 6 months follow-up. All patients underwent bilateral ultrasound examination of the three temporal artery (TA) segments and axillary arteries, prior to TA biopsy. The extent of vascular inflammation was quantified by (1) counting the number of TA segments and axillary arteries with a halo and (2) calculating a composite Halo Score that also incorporated the thickness of each halo. RESULTS: Halo counts and Halo Scores showed moderate diagnostic accuracy for a clinical diagnosis of GCA. They correlated positively with systemic inflammation. When compared with the halo count, the Halo Score correlated better with C-reactive protein (CRP) levels and allowed to firmly establish the diagnosis of GCA in more patients. Higher halo counts and Halo Scores were associated with a higher risk of ocular ischaemia. They allowed to identify subgroups of patients with low risk (≤5%) and high risk of ocular ischaemia (>30%). CONCLUSIONS: Ultrasound halo scoring allows to quantify the extent of vascular inflammation in GCA. Extensive vascular inflammation on ultrasound may provide strong diagnostic confirmation and associates with ocular ischaemia in GCA.

Assessment of Orbital Computed Tomography (CT) Imaging Biomarkers in Patients with Thyroid Eye Disease.

To understand potential orbital biomarkers generated from computed tomography (CT) imaging in patients with thyroid eye disease. This is a retrospective cohort study. From a database of an ongoing thyroid eye disease research study at our institution, we identified 85 subjects who had both clinical examination and laboratory records supporting the diagnosis of thyroid eye disease and concurrent imaging prior to any medical or surgical intervention. Patients were excluded if imaging quality or type was not amenable to segmentation. The images of 170 orbits were analyzed with the developed automated segmentation tool. The main outcome measure was to cross 25 CT structural metrics for each eye with nine clinical markers using a Kendall rank correlation test to identify significant relationships. The Kendall rank correlation test between automatically calculated CT metrics and clinical data demonstrated numerous correlations. Extraocular rectus muscle metrics, such as the average diameter of the superior, medial, and lateral rectus muscles, showed a strong correlation (p < 0.05) with loss of visual acuity and presence of ocular motility defects. Hertel measurements demonstrated a strong correlation (p < 0.05) with volumetric measurements of the optic nerve and other orbital metrics such as the crowding index and proptosis. Optic neuropathy was strongly correlated (p < 0.05) with an increase in the maximum diameter of the superior muscle. This novel method of automated imaging metrics may provide objective, rapid clinical information. This data may be useful for appreciation of severity of thyroid eye disease and recognition of risk factors of visual impairment from dysthyroid optic neuropathy from CT imaging.

Extraintestinal Manifestations of Inflammatory Bowel Disease: Epidemiology, Etiopathogenesis, and Management.

PURPOSE OF REVIEW: Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) represent a complex array of disease processes with variable epidemiologic penetrance, genetic antecedents, and phenotypic presentations. The purpose of this review is to provide an overview of primary and secondary EIMs as well as salient treatment strategies utilized. RECENT FINDINGS: While the genetic antecedents remain incompletely understood, the treatment armamentarium for EIMs has expanded with new pharmaceutical drug classes that effectively treat IBD. EIMs are an increasingly recognized complication of IBD that require prompt recognition, multidisciplinary management, and a multifaceted therapeutic approach. This review highlights the complexities and ramifications of EIM management and offers therapeutic guidance.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives.

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Anterior segment ischemia: etiology, assessment, and management.

Anterior segment ischemia (ASI) is a potentially serious but rare complication of strabismus surgery. Among several risk factors, ASI occurs after strabismus surgery because of the nature of the anterior segment circulation. Disinsertion of rectus muscles leads to a decrease in the blood supply to the various anterior segment structures. We report a series of retrospective and prospective studies performed by our group focused on determining the risk of anterior segment ischemia following strabismus surgery, diagnosis, and modifications to surgical techniques to minimize the impact on anterior segment circulation. We found a significant decrease in postoperative anterior segment blood flow when operating vertical rectus muscles. Plication procedures preserve anterior segment circulation, and modifications to the technique allow the performance of adjustable sutures. Small adjustable selective procedures that spare the ciliary vessels have been demonstrated to be effective in patients with vertical and torsional diplopia. Ciliary sparing augmented adjustable transposition surgery decreases the risk of anterior segment ischemia while allowing management of potential post-operative alignment complications. Finally, ocular coherence tomography angiography is a valuable quantitative and qualitative technique to evaluate anterior segment ischemia. Strabismus surgeons should be aware of the risks of anterior segment ischemia when operating vertical rectus muscles. Modifications to standard surgical techniques allow surgeons to perform complex strabismus surgery in patients at risk for anterior segment ischemia.

Multidisciplinary assessment of post-Ebola sequelae in Guinea (Postebogui): an observational cohort study.

BACKGROUND: The high number of survivors from the 2013-16 west African outbreak of Ebola virus disease (EVD) has raised several new issues: long-term clinical complications, psychosocial consequences, risks of EVD reactivation, and secondary transmission due to viral persistence in body fluids. We aimed to assess long-term clinical, psychosocial, and viral outcomes in EVD survivors in Guinea. METHODS: In this multidisciplinary observational cohort study, we recruited patients aged 1 year or more in four sites in Guinea (Donka National Hospital, Conakry; Macenta Prefectoral Hospital, Macenta; N'zérékoré Regional Hospital, N'zérékoré; and Forécariah Prefectoral Hospital, Forécariah) following discharge from any Ebola treatment centre in Guinea. Eligible patients had had laboratory-confirmed EVD and had then been declared clear of the virus in the blood. All consenting patients were included, with no exclusion criteria. Trained clinicians assessed patients at enrolment to the cohort, recording clinical symptoms and signs of depression. We did routine blood examinations and examined viral persistence in body fluids using RT-PCR. We did psychological evaluations using questionnaires developed for different age groups. Follow-up is planned to 2 years, and here we present findings at enrolment. FINDINGS: Between March 23, 2015, and July 11, 2016, we recruited 802 patients, of whom 360 (45%) were male, 442 (55%) were female; 158 (20%) were younger than 18 years. The median age was 28·4 years (range 1·0-79·9, IQR 19·4-39·8). The median delay after discharge was 350 days (IQR 223-491). The most frequent symptoms were general symptoms (324 [40%] patients), musculoskeletal pain (303 [38%]), headache (278 [35%]), depression (124 [17%] of 713 responses), abdominal pain (178 [22%]), and ocular disorders (142 [18%]). More adults than children had at least one clinical symptom (505 [78%] vs 101 [64%], p<0·0003), ocular complications (124 [19%] vs 18 [11%], p=0·0200), or musculoskeletal symptoms (274 [43%] vs 29 [18%], p<0·0001). A positive RT-PCR in semen was found in ten (5%) of 188 men, at a maximum of 548 days after disease onset. 204 (26%) of 793 patients reported stigmatisation. Ocular complications were more frequent at enrolment than at discharge (142 [18%] vs 61 [8%] patients). INTERPRETATION: Post-EVD symptoms can remain long after recovery and long-term viral persistence in semen is confirmed. The results justify calls for regular check-ups of survivors at least 18 months after recovery. FUNDING: INSERM/Reacting, the French Ebola Task Force, and Institut de Recherche pour le Développement.

Canadian Clinical Practice Guidelines for Rosacea.

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

Risk of Ocular Complications in Patients with Noninfectious Intermediate Uveitis, Posterior Uveitis, or Panuveitis.

PURPOSE: Noninfectious uveitis results in vision loss and ocular complications without adequate treatment. We compared the risk of developing ocular complications between patients with noninfectious intermediate uveitis, posterior uveitis, or panuveitis (NIIPPU) and matched controls. DESIGN: Retrospective analysis of insurance claims data (OptumHealth, Eden Prairie, MN; January 1, 1998-March 31, 2012). PARTICIPANTS: Cases 18 to 64 years of age with 2 or more NIIPPU diagnoses (International Classification of Diseases, 9th Revision, Clinical Modification codes) were matched 1:1 by sex, age, region, company, employment status, and index date with controls without uveitis. Patients with an ocular complication during baseline were excluded. METHODS: Continuous eligibility for 6 months or more before the first NIIPPU diagnosis date was required. Risks of ocular complications developing during patients' continuous eligibility in the study period were compared using unadjusted Kaplan-Meier survival analysis to estimate risk of and time to complications and adjusted Cox regression analysis to estimate hazard ratios (HRs). MAIN OUTCOME MEASURES: Percentages of cases and controls who demonstrate ocular complications and 1-, 5-, and 10-year risks and HRs for each complication. RESULTS: Mean age of the 1769 cases and matched controls was 47 years and 47% were men; 302 cases had persistent NIIPPU. During the study period, NIIPPU cases had a higher risk of any ocular complication (P < 0.001); the 5-year risk of any ocular complication was 66% for patients versus 24% for controls. Specifically, NIIPPU patients had greater 5-year risks of glaucoma (20% vs. 9%), cataract (35% vs. 13%), visual disturbance (29% vs. 9%), blindness or low vision (5% vs. 0.5%), retinal detachment (11% vs. 0.8%), and retinal disorder (28% vs. 2%) compared with controls. Hazard ratios indicated greater risks of ocular complications in cases versus controls during the overall observation period (HR, 5.2 for any ocular complication; HR, 4.8 for visual disturbance; HR, 3.2 for cataract; and HR, 2.7 for glaucoma; all P < 0.001). Hazard ratios for persistent cases indicated even greater risks. CONCLUSIONS: Noninfectious intermediate uveitis, posterior uveitis, or panuveitis, particularly persistent disease, is associated with a substantial risk of ocular complications. Optimal treatment initiatives remain imperative to reduce the ocular complication-related burden of NIIPPU.

[Patient-Centred Care of Ocular Graft-vs-Host Disease in Germany]. / Versorgungsstrukturen der okulären Graft-versus-Host Disease in Deutschland.

BACKGROUND: Ocular GvHD is a severe complication following allogenic blood stem cell transplantation leading to massive reduction in quality of life and ocular pathologies including corneal perforation. Interdisciplinary patient-centred care needs to be performed in specialized ophthalmic centers that provide all diagnostic and therapeutic options, however, only few clinics have the necessary infrastructure. In addition there is a lack of transparency and easily accessible information for the patients regarding ophthalmic care and specialized centres. For this reason the "Ocular GvHD working group" within the Cornea Section of the German Society of Ophthalmology has been founded to evaluate and improve patient-centered care in ocular GvHD within Germany. METHODS: A survey was performed among the members of the Cornea Section of the German Society of Ophthalmology and the Directors of Departments of Ophthalmology in Germany that evaluated the number of annual examinations, presence of specialized GvHD outpatient clinics and eye screenings prior to allogenic blood stem cell transplantation (aBSCT). RESULTS: 25 clinics (19 university hospitals, 6 general hospitals) responded to the survey. In 18 clinics aBSCT are performed. Between 5 and 200 patients after aBSCT are examined per year per clinic. Larger institutions are associated with departments of haemato-oncology and other specialised disciplines to facilitate an interdisciplinary patient care. Three clinics are associated with GvHD competence centres. The major challenge in establishing an appropriate infrastructure for better patient-centered care is the limited or lacking reimbursement by health insurances. CONCLUSIONS: Within Germany only few ophthalmic centres exist that provide state-of-the-art patient-centered care for ocular GvHD. The present structures are not sufficient to treat all patients undergoing aBSCT following existing guidelines. Joint efforts are necessary to establish more and accessible competence centers for ocular GvHD with sufficient personnel and structural resources. In addition, ocular GvHD should be included as a mandatory topic in medical training and transparent and easily accessible information needs to be provided for patients and health-care professionals.

Positioning-related complications of minimally invasive radical prostatectomies.

BACKGROUND AND PURPOSE: Because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (RARP) has become the primary treatment option in prostate cancer. RARP, however, necessitates patients to be placed in a steep Trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. Our study aims to study the prevalence and demographic predictors of these positioning complications and assess their impacts on length of stay (LOS) and total cost. PATIENTS AND METHODS: We included patients who underwent RP from 2008 to 2009 using data extracted from the Nationwide Inpatient Sample database. Positioning complications (eye, nerve, compartment syndrome/rhabdomyolysis) were identified using patient-level diagnosis and procedural International Classification of Disease, 9th edition, Clinical Modification codes. Logistic regression models assessed relationships between demographic factors and occurrence of complications and the effects of them on prolonged LOS and total inpatient cost. RESULTS: Positioning complications occurred in 0.4% of cases with eye complications contributing the most to this frequency. Laparoscopic RP procedure (odds ratio [OR]=2.88, P<0.01) and comorbidities (OR=2.34, P<0.01) were highly associated with increased odds of positioning complication occurrence, whereas RARP procedures (OR=0.93, P>0.4) were not associated with positioning complications. Having positioning complications increased a patient's odds of having increased inpatient costs and extended LOS by almost 400% and 300%, respectively. CONCLUSION: The steep Trendelenberg position used in RARP was not shown to be associated with patient positioning-related complications in this sample. The occurrence of positioning-related complications, however, places huge burdens on total inpatient costs and LOS.

Epidemiology of ophthalmologic disease associated with erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis in hospitalized children in the United States.

The objective of the current study was to characterize the epidemiology and resource use of U.S. children hospitalized with ophthalmologic disease secondary to erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). We studied children ages 5 to 19 years hospitalized in 2005 in 11 states, encompassing 38% of the U.S. pediatric population. Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, we identified admissions of children with EM, SJS, or TEN and the presence of concurrent ophthalmologic disease, analyzed patient and hospitalization characteristics, and generated age- and sex-adjusted national estimates. We identified 460 children admitted with EM, SJS, or TEN, corresponding to 1,229 U.S. hospitalizations in 2005. Of the children with EM, SJS, or TEN, 60 (13.0%) had ophthalmologic disease, primarily (90.0%) disorders of the conjunctiva. Children with the highest proportions of ophthalmologic disease included those with mycoplasma pneumonia (26.7%), herpes simplex virus (15.6%), upper respiratory infection (13.9%), and lower respiratory infection (13.7%). Individuals with EM, SJS, or TEN and ophthalmologic disease were more likely than those without ophthalmologic disease to receive intensive care unit care (28.3% vs 17.0%, p = 0.03) and to be admitted to a children's hospital (63.3% vs 48.8%, p = 0.03). Ophthalmologic disease was also associated with a significantly longer median length of stay (6.0 days, interquartile range [IQR] 3-9 days vs 3.0 days, IQR 2-6 days, p < 0.001) and median hospital cost ($7,868, IQR $3,539-$17,440 vs $2,969, IQR $1,603-$8,656, p < 0.001). In children with EM, SJS, or TEN, ophthalmologic disease was most common in those with concurrent Mycoplasma pneumoniae and herpes simplex virus infections. Ophthalmologic disease was associated with considerably higher inpatient resource use in this population. Children with EM, SJS, or TEN should be screened and treated early for ophthalmologic disease to prevent morbidity and minimize long-term sequellae.

Cheaper fuel and higher health costs among the poor in rural Nepal.

Biomass fuels are used by the majority of resource poor households in low-income countries. Though biomass fuels, such as dung-briquette and firewood are apparently cheaper than the modern fuels indoor pollution from burning biomass fuels incurs high health costs. But, the health costs of these conventional fuels, mostly being indirect, are poorly understood. To address this gap, this study develops probit regression models using survey data generated through interviews from households using either dung-briquette or biogas as the primary source of fuel for cooking. The study investigates factors affecting the use of dung-briquette, assesses its impact on human health, and estimates the associated household health costs. Analysis suggests significant effects of dung-briquette on asthma and eye diseases. Despite of the perception of it being a cheap fuel, the annual health cost per household due to burning dung-briquette (US$ 16.94) is 61.3% higher than the annual cost of biogas (US$ 10.38), an alternative cleaner fuel for rural households. For reducing the use of dung-briquette and its indirect health costs, the study recommends three interventions: (1) educate women and aboriginal people, in particular, and make them aware of the benefits of switching to biogas; (2) facilitate tree planting in communal as well as private lands; and (3) create rural employment and income generation opportunities.

Dural carotid-cavernous fistulas: epidemiology, clinical presentation, and management.

Dural arteriovenous fistulas of the cavernous sinus are no longer difficult to diagnose or treat. Specific ocular manifestations allow these fistulas to be diagnosed clinically. Noninvasive imaging techniques can be used to confirm the diagnosis. The most common treatment is endovascular occlusion of the lesion via a transarterial or transvenous route. Manual compression of the ipsilateral internal carotid artery in the neck or radiation therapy is appropriate in selected cases. Regardless of the treatment used, the fistula can be closed completely in most cases, resulting in restoration of normal orbital and intracranial blood flow and resolution of visual deficits.

Ocular complications after anti-vascular endothelial growth factor therapy in Medicare patients with age-related macular degeneration.

PURPOSE: To determine longitudinal rates of ocular complications after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD) in a nationally representative longitudinal sample. DESIGN: Retrospective, longitudinal case-control study. METHODS: Using the Medicare 5% claims database, diagnoses of neovascular AMD and anti-VEGF injections of ranibizumab, bevacizumab, or pegaptanib were identified from International Classification of Diseases and Current Procedural Terminology procedure codes. Six thousand one hundred fifty-four individuals undergoing anti-VEGF treatment for neovascular AMD (total of 40 903 injections) were compared with 6154 matched controls with neovascular AMD who did not undergo anti-VEGF treatment. Propensity score matching was used to match individuals receiving anti-VEGF injections with controls. Rates of postinjection adverse outcomes (endophthalmitis, rhegmatogenous retinal detachment, retinal tear, uveitis, and vitreous hemorrhage) were analyzed by cumulative incidence and Cox proportional hazards model to control for demographic factors and ocular comorbidities. RESULTS: At the 2-year follow-up, the rates of endophthalmitis per injection (0.09%; P<.01), uveitis (0.11%; P<.01), and vitreous hemorrhage per injection (0.23%; P < .01) were significantly higher in the anti-VEGF treatment group. With Cox proportional hazards modeling, the anti-VEGF treatment group had a 102% higher risk of severe ocular complications overall and a 4% increased risk per injection, both of which were statistically significant (P<.01). CONCLUSIONS: Rates of endophthalmitis, uveitis, and vitreous hemorrhage were higher in the group treated with anti-VEGF injection than in the control group, although these nevertheless were rare in both groups. The overall risk of severe ocular complications was significantly higher in the anti-VEGF treatment group.

Ophthalmic assessment of children with down syndrome: is England doing its bit?

INTRODUCTION: Patients with Down syndrome have characteristic features including ocular manifestations. Guidelines exist for ophthalmic surveillance of people with Down syndrome, but locally (North Staffordshire) there is no formal program in place. METHODS: Hospital records were used to detect children with Down syndrome. Data were extracted retrospectively to determine which children had been seen by ophthalmic services, the mode of assessment used, and the frequency of ophthalmic disorders. RESULTS: Of the 96 children with Down syndrome, 38% received no ophthalmic assessment. Of those seen, the mean age at first appointment was nearly 3 years, with a number of children being more than 5 years old. Most children (96%) had at least one ophthalmic abnormality, the commonest being hyperopia. Requested follow-up was routinely exceeded by almost a year with 19% of children receiving no follow-up. DISCUSSION: Ocular disorders are common in the two thirds of children who are currently seen by ophthalmic services. Locally, we are falling short of the targets set by the 2006 recommendations for basic medical care of people with Down syndrome. A screening program might have a beneficial impact on the vision of children with Down syndrome.