Intraoperative choroidal detachment during 23-gauge vitrectomy.

PURPOSE: To review intraoperative choroidal detachments during 23-gauge vitrectomy and examine possible mechanism(s) involved. METHODS: A retrospective consecutive case review of 23-gauge vitrectomies was performed. Main outcomes included choroidal detachment incidence, location, extent, relation to infusion cannula, and postoperative course. Laboratory study of human donor eyes was conducted by placing 23-gauge cannulas at various angles through the pars plana and injecting viscoelastic material after cannula retraction. RESULTS: Among 338 consecutive 23-gauge vitrectomy cases, 12 (3.55%) intraoperative choroidal detachments occurred. These included 6 (1.77%) serous detachments, 4 (1.18%) limited hemorrhagic detachments, and 1 case each of gas and silicone oil during an exchange. In four of six serous detachments and three of four hemorrhagic detachments, the detachment originated from the infusion cannula site. Intraoperative infusion cannula retraction (5 of 12 cases) and blockage (2 of 12 cases) caused transient hypotony. All cases of serous, hemorrhagic, and gas detachment resolved without intervention. Cannulas were placed at various angles to the sclera in human donor eyes. Choroidal detachments were produced after injecting viscoelastic material through obliquely placed cannulas after 1 mm of retraction. CONCLUSION: Infusion cannula retraction is an important mechanism and risk factor for the development of intraoperative choroidal detachment during 23-gauge vitrectomy. Precautions to prevent retraction and intraoperative repositioning may help avoid this complication.

Validation of the Pediatric Vision Scanner in a normal preschool population.

PURPOSE: To assess the Pediatric Vision Scanner (PVS), a handheld vision screening device designed to test for amblyopia and strabismus, in a general pediatric population. METHODS: In this prospective study, trained research staff screened 300 eligible children 24-72 months of age with no known eye conditions for amblyopia and strabismus using the PVS. A pediatric ophthalmologist masked to PVS screening results then performed a comprehensive eye examination. Sensitivity and specificity of the PVS was calculated with a 95% confidence interval. RESULTS: Based on the gold standard eye examination, 6 children (2%) had amblyopia and/or strabismus. The PVS detected all 6 cases, yielding a sensitivity rate of 100% (95% CI, 54%-100%). The PVS referred 45 additional children (15%) who had normal ophthalmic findings, yielding a specificity rate of 85% (95% CI, 80%-89%). The median acquisition time for the PVS was 28 seconds. CONCLUSIONS: The PVS detected amblyopia with high sensitivity in a nonenriched pediatric population. The device would allow children with amblyopia and/or strabismus to be referred to an eye care specialist as early as 2 years old. Given its short acquisition time, the PVS can be implemented in a pediatric clinic with minimal impact on workflow.

Comparison of microbiology and visual outcomes of patients undergoing small-gauge and 20-gauge vitrectomy for endophthalmitis.

BACKGROUND: The role of pars plana vitrectomy (PPV) for endophthalmitis has evolved over recent decades but the literature is lacking on comparisons between small-gauge and 20-gauge vitrectomy. OBJECTIVE: To evaluate evolving etiological and microbiological trends in patients undergoing vitrectomy for endophthalmitis and to compare culture-positive rates and visual outcomes between small-gauge (23- and 25-gauge) and 20-gauge instrumentation during vitrectomy for endophthalmitis. METHODS: Ten-year retrospective comparative case series and prospective laboratory in vitro testing. Tertiary care academic referral center. Patients who underwent PPV for endophthalmitis between 2003 and 2013. Vitreous biopsies were obtained in all cases. The effect of vitrectomy gauge (20-, 23-, and 25-gauge) and vitreous cutting rate (1,500 and 5,000 cuts per minute) on the viability of bacterial culture was evaluated in an in vitro prospective laboratory investigation. MAIN OUTCOME MEASURES: Comparison of etiology, microbiology culture-positive rates, and visual outcomes between small-gauge and 20-gauge instrumentation in patients undergoing PPV for infectious endophthalmitis. RESULTS: A total of 61 cases of vitrectomy for endophthalmitis were identified over a 10-year period; of these, 34 were treated with small-gauge (23- and 25-gauge) vitrectomy and 27 were treated with 20-gauge vitrectomy. In the small-gauge group, 12 cases (35.3%) yielded culture-positive results versus 20 cases (74.1%) with culture positivity in the 20-gauge cohort (P=0.002). The most common cause of endophthalmitis was cataract surgery and the most frequently identified organism was coagulase-negative Staphylococci in both groups. There was no significant difference in mean postoperative visual acuities between groups (P=0.33). Etiological trends indicate an increase in endophthalmitis due to intravitreal injection in the small-gauge group (n=9) compared to the 20-gauge group (n=3) (P=0.001). In vitro laboratory testing revealed no significant difference in rates of culture growth for different vitrectomy gauge sizes or vitreous cutting speeds. CONCLUSION AND RELEVANCE: Small-gauge vitrectomy for endophthalmitis yields final visual outcomes comparable to 20-gauge instrumentation. A significant difference in culture-positive rates was observed between small-gauge and 20-gauge instrumentation for vitrectomy in endophthalmitis; however, laboratory testing indicates this is not related to either vitreous gauge size or cutter speed. Intravitreal injections are emerging as a common etiology of vitrectomy for endophthalmitis.

Validity of a layperson-administered Web-based vision screening test.

PURPOSE: To determine the sensitivity and specificity of the Web-based vision-screening test (WBT) VisionForKids.org when administered by an untrained layperson in a controlled environment. METHODS: Visual acuities were obtained by an untrained layperson using the WBT under observation and by an ophthalmic professional using the Electronic Visual Acuity (EVA) Tester. Subjects were randomized to which method was used first. Subjects were considered to have failed by the following criteria: in children <48 months, 20/50 vision; in children between 48 and 59 months, 20/40 or worse; in children ≥60 months, 20/30 or worse. The results of the vision examinations by the WBT and the EVA Tester were compared; sensitivity and specificity of the WBT and the correlation coefficient to detect normal and abnormal vision compared to EVA testing were determined. RESULTS: Visual acuities were obtained on 203 children between ages 3 and 12 years (average age, 7.4 years). Sensitivity of the WBT was 78.7% (95% CI, 66.0%-87.7%), specificity was 89.4% (95% CI, 82.9%-93.8%). The correlation coefficient of EVA testing with the WBT was 0.89 (P < 0.001). CONCLUSIONS: This layperson-administered WBT, VisionForKids.org, is valid for identifying amblyopia in a controlled environment, making it possible for cost-effective and easily accessible vision screening to be performed by laypersons.

A biorepository for ophthalmic surgical specimens.

Biorepositories are collections of surgically obtained human tissues for current and future investigations of disease mechanisms, therapeutics, and diagnostics. In ophthalmology, a critical challenge is how to interface the operating room with the laboratory. To attain standards required for basic research, clinical and research teams must cooperate to collect, annotate, and store specimens that yield consistent results required for advanced molecular techniques. We developed an efficient platform for obtaining vitreous and other eye tissues from the operating room and transferring them to the lab. The platform includes a mobile lab cart for on-site tissue processing, a multi-user, web-based database for point-of-care phenotypic capture, and an integrated data tracking system for long-term storage. These biorepository instruments have proven essential for our studies in ophthalmic disease proteomics. This system can be implemented in other operating rooms and laboratories for a variety of biological tissues.

Erythropoetin receptor expression in the human diabetic retina.

BACKGROUND: Recent evidence suggests erythropoietin (EPO) and the erythropoietin receptor (EPOR) may play a direct role in the pathogenesis of diabetic retinopathy. Better characterization of the EPO-EPOR signaling system in the ischemic retina may offer a new therapeutic modality for ischemic ophthalmic diseases. This study was performed to identify EPOR mRNA expression in the human diabetic eye. FINDINGS: EPOR antisense RNA probes were validated on human pancreas tissue. In the normal eye, EPOR was expressed in the retinal ganglion cell layer. Minimal expression was observed in the inner and outer nuclear layer. Under conditions of diabetic retinopathy, EPOR expression shifted to photoreceptor cells. Increased expression was also observed in the peripheral retina. CONCLUSION: EPOR expression may be a biomarker or contribute to disease mechanisms in diabetic retinopathy.

Who is providing and who is getting asthma patient education: an analysis of 2001 National Ambulatory Medical Care Survey data.

Patient education in asthma management is important; however, there is little known about the characteristics of patients receiving asthma education or how often primary care physicians provide it. The objective of the study was to identify the characteristics of patients receiving asthma education. It was a cross-sectional study using 2001 National Ambulatory Medical Care Survey data. The study included 1230 physicians providing office-based ambulatory medical care in the United States. Patients in the study (weighted n=11,279,952) were those diagnosed with asthma based on International Classification of Diseases, 9th Revision code receiving care from a pediatrician, internist or a family physician. Main and secondary outcome measures were asthma education ordered or provided. Multivariate analysis indicated that asthma patients receiving education were more likely to have office visits >20 min [odds ratio (OR) = 3.934], be seen for an acute reason (OR = 2.268), be seen in follow-up rather than an initial visit (OR = 1.780), live in rural rather than metropolitan areas (OR = 1.507), have public rather than private insurance (OR = 1.276) and be seen in privately owned practices (OR = 1.248). Bivariate analyses indicated that patients seeing family physicians were more likely than those seeing internists or pediatricians to receive education. Patient education was not uniformly provided. Family physicians provided more asthma education than either pediatricians or internists. Future research should investigate the quality of education provided.

Mutation in the SLC4A11 gene associated with autosomal recessive congenital hereditary endothelial dystrophy in a large Saudi family.

OBJECTIVE: To determine the role of the SLC4A11 gene in two pedigrees affected with autosomal recessive congenital hereditary endothelial dystrophy (CHED). METHODS: Nine members of a pedigree from the Kingdom of Saudi Arabia (pedigree 971G) and 2 twins in a pedigree from Bosnia (pedigree GGO413) were diagnosed with autosomal recessive CHED and contributed DNA samples for genetic studies. The proband of each pedigree was tested for disease-causing mutations in the SLC4A11 gene with bi-directional DNA sequencing. Screening assays using restriction enzyme digests were developed to test a cohort of 99 normal control subjects for the presence of SLC4A11 mutations. RESULTS: A novel, homozygous mutation in the SLC4A11 gene (Thr271Met) was detected in the proband of pedigree 971G. Homozygous Thr271Met mutations were detected in all affected members of pedigree 971G. The Thr271Met mutation was not detected in a cohort of 99 normal control subjects. This mutation alters a highly conserved amino acid in the encoded SLC4A11 protein. No SLC4A11 mutations were detected in pedigree GGO413. CONCLUSION: A novel SLC4A11 mutation (Thr271Met) is associated with autosomal recessive CHED in a pedigree from the Kingdom of Saudi Arabia and provides additional support that mutations in this gene cause disease.