Combined epiretinal and internal limiting membrane retracting door flaps for large macular holes associated with epiretinal membranes.

PURPOSE: To assess the closure rate of large full-thickness macular holes (FTMH) associated with epiretinal membrane (ERM) with a combined epiretinal and internal limiting membrane retracting door flap. METHODS: Retrospective chart review of patients treated at a single tertiary retina practice between January 2017 and November 2019. Individuals with FTMH larger than 400 µm and co-diagnosis of ERM who underwent surgical repair with an ERM flap were included. Patients underwent pars plana vitrectomy with peeling of ERM that was positioned as a retracting door flap to cover the FTMH. Primary outcome was closure rate at 6 months following surgery. Final surgical success rate and visual acuity were secondary outcomes. RESULTS: Among 7 eyes of 7 patients, 6 eyes achieved primary surgical success and final surgical success rate was achieved in all 7 eyes with a large FTMH repaired with ERM flap. The mean minimum linear diameter of the FTMH was 681 µm ± 295. All patients had follow-up greater than 6 months, with a mean duration of 17 months (range 14-23 months). Visual acuity improved from a mean of 0.9 ± 0.3 logMar (20/160) before surgery to 0.3 ± 0.5 logMar (Snellen 20/40), postoperatively. CONCLUSION: Large FTMH with concurrent ERM that are managed with an ERM flap have high single-surgery success rate.

Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) Versus Standard of Care for Postsurgical Lagophthalmos and Exposure Keratopathy: Trends in Visual Outcomes.

PURPOSE: To compare baseline characteristics and visual acuity outcomes in patients treated with prosthetic replacement of the ocular surface ecosystem (PROSE) versus other standard-of-care (SOC) treatments for postsurgical lagophthalmos and exposure keratopathy. METHODS: An institutional review board-approved, retrospective cohort study of 45 consecutive patients (53 eyes) with postsurgical lagophthalmos and exposure keratopathy following oculoplastic or skull base surgeries treated between August 2011 and August 2017 was performed. Patients treated with PROSE (22 patients, 27 eyes) were identified by referrals made to the PROSE treatment program at Weill Cornell Medical College. Patients treated with SOC treatments (23 patients, 26 eyes) were identified by International Classification of Diseases-9 and International Classification of Diseases-10 search of billing records. SOC treatments included ocular surface lubrication (artificial tears and/or punctal plugs), tape tarsorrhaphy and/or moisture chamber, or surgical correction. The primary outcome measure was best-corrected visual acuity converted to logMAR at baseline and at 1, 3, 6, and 12 months. Secondary outcome measures were subjective patient reports of improvement in vision and comfort, as well as presence of punctate epithelial erosions and/or corneal haze on slit-lamp examination before and after treatment. RESULTS: Average age for all patients was 52 ± 22 years (range: 7-87). Twenty-eight (62%) of total patients were male. Baseline corrected logMAR visual acuity was 0.58 ± 0.40 (20/76) for PROSE and 0.27 ± 0.39 (20/37) for SOC cohorts (p < 0.001). Mean number of failed prior treatments was 8.3 ± 3 for PROSE and 2.1 ± 2 for SOC (p < 0.0001). Mean difference in logMAR visual acuity for PROSE versus SOC, respectively, from baseline to 1 month was 0.33 ± 0.26 (3-line improvement) versus 0.01 ± 0.17 (no line improvement; p < 0.0001), to 3 months was 0.31 ± 0.23 (3-line improvement) versus 0.08 ± 0.30 (4-letter improvement; p = 0.0004), to 6 months was 0.31 ± 0.28 (3-line improvement) versus 0.10 ± 0.36 (1-line improvement; p = 0.02), and to 12 months was 0.32 ± 0.28 (3-line improvement) versus 0.12 ± 0.34 (1-line improvement; p = 0.01). CONCLUSIONS: Patients with postsurgical lagophthalmos and exposure keratopathy treated with PROSE are more likely to have failed a higher number of treatments and have worse initial best-corrected visual acuities than those treated with SOC. Prosthetic replacement of the ocular surface ecosystem causes rapid and substantial visual improvement within 1 month of use compared with SOC, with little change beyond this time and sustained best-corrected visual acuity at 3, 6, and 12 months after treatment.

SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN MACULA-INVOLVING CYTOMEGALOVIRUS RETINITIS.

PURPOSE: To evaluate the microstructural features of cytomegalovirus (CMV) retinitis by spectral domain optical coherence tomography (OCT). METHODS: Subjects were patients with macula-involving CMV retinitis with OCT imaging. The leading edge of retinitis in the macula was identified based on fundus imaging, and OCT findings were longitudinally evaluated in three areas: within the area of active retinitis, at the leading edge of retinitis, and just beyond the leading edge of retinitis. RESULTS: Optical coherence tomography imaging of macular CMV retinitis identified vitreous cells in 10 eyes (100%), posterior vitreous detachment in four eyes (40%), broad-based vitreomacular traction in one eye (10%), epiretinal membrane in eight eyes (80%), and lamellar hole-associated epiretinal proliferation associated with an atrophic hole in one eye (10%). Retinal architectural disruption, disruption of inner retinal layers, disruption of the external limiting membrane, and ellipsoid zone abnormalities were noted within the area of retinitis in all eyes and decreased in frequency and severity at and beyond the leading edge of retinitis, although all 10 eyes (100%) exhibited one of these abnormalities, especially outer retinal microabnormalities, beyond the leading edge of retinitis. CONCLUSION: Microstructural abnormalities were frequently noted on OCT of CMV retinitis, including within the retina beyond the leading edge of retinitis identified by corresponding fundus imaging. Outer retinal abnormalities were noted more frequently than inner retinal abnormalities beyond the leading edge of retinitis. These findings provide insight into the effects of CMV retinitis on retinal microstructure and potentially on vision and highlight the potential utility of OCT for monitoring microprogression of macula-involving CMV retinitis.

A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis.

OBJECTIVES: This study conducted a randomized controlled trial with 600 recently released homeless men exiting California jails and prisons. METHODS: The purpose of this study was to primarily ascertain how different levels of intensity in peer coaching and nurse-partnered intervention programs may impact reentry outcomes; specifically: (a) an intensive peer coach and nurse case managed (PC-NCM) program; (b) an intermediate peer coaching (PC) program with brief nurse counseling; and (c) the usual care (UC) program involving limited peer coaching and brief nurse counseling. Secondary outcomes evaluated the operational cost of each program. RESULTS: When compared to baseline, all three groups made progress on key health-related outcomes during the 12-month intervention period; further, 84.5 % of all participants eligible for hepatitis A/B vaccination completed their vaccine series. The results of the detailed operational cost analysis suggest the least costly approach (i.e., UC), which accounted for only 2.11 % of the total project expenditure, was as effective in achieving comparable outcomes for this parolee population as the PC-NCM and PC approaches, which accounted for 53.98 % and 43.91 %, respectively, of the project budget. CONCLUSIONS: In this study, all three intervention strategies were found to be comparable in achieving a high rate of vaccine completion, which over time will likely produce tremendous savings to the public health system.

Nurses, formerly incarcerated adults, and Gadamer: phronesis and the Socratic dialectic.

This paper describes the first phase of an ongoing education and research project guided by three main intentions: (1) to create opportunities for phronesis in the classroom; (2) to develop new understandings about phronesis as it relates to nursing care generally and to caring for specific groups, like formerly incarcerated adults; and (3) to provide an opportunity for formerly incarcerated adults and graduate nursing students to participate in a dialectical conversation about ethical knowing. Gadamer's writings on practical philosophy, phronesis, and the Socratic dialectic provide the philosophical foundation and framework for the project. The first phase in the project was a 4-h class within a graduate-level health promotion course during which 30 nursing students and three formerly incarcerated panelists engaged in a dialectic conversation about what it means to care for formerly incarcerated adults in a meaningful way. After the class, two focus groups were conducted, one with the students and one with the formerly incarcerated panelists. Findings articulated participants' prejudices and assumptions prior to the class, expanded sense of phronesis, and ability to consider nursing practice within a larger ethical framework. Panelists and students left the class with a deeper understanding of one another and expressed an openness towards continued dialectic conversations together. Use of the Socratic dialectic within nursing curricula reflects a current and critical trend in nursing education to bring non-epistemologic forms of knowledge into the classroom.

Differentiated Parkinson patient-derived induced pluripotent stem cells grow in the adult rodent brain and reduce motor asymmetry in Parkinsonian rats.

Recent advances in deriving induced pluripotent stem (iPS) cells from patients offer new possibilities for biomedical research and clinical applications, as these cells could be used for autologous transplantation. We differentiated iPS cells from patients with Parkinson's disease (PD) into dopaminergic (DA) neurons and show that these DA neurons can be transplanted without signs of neurodegeneration into the adult rodent striatum. The PD patient iPS (PDiPS) cell-derived DA neurons survived at high numbers, showed arborization, and mediated functional effects in an animal model of PD as determined by reduction of amphetamine- and apomorphine-induced rotational asymmetry, but only a few DA neurons projected into the host striatum at 16 wk after transplantation. We next applied FACS for the neural cell adhesion molecule NCAM on differentiated PDiPS cells before transplantation, which resulted in surviving DA neurons with functional effects on amphetamine-induced rotational asymmetry in a 6-OHDA animal model of PD. Morphologically, we found that PDiPS cell-derived non-DA neurons send axons along white matter tracts into specific close and remote gray matter target areas in the adult brain. Such findings establish the transplantation of human PDiPS cell-derived neurons as a long-term in vivo method to analyze potential disease-related changes in a physiological context. Our data also demonstrate proof of principle of survival and functional effects of PDiPS cell-derived DA neurons in an animal model of PD and encourage further development of differentiation protocols to enhance growth and function of implanted PDiPS cell-derived DA neurons in regard to potential therapeutic applications.

Correlates of serious violent crime for recently released parolees with a history of homelessness.

This study used baseline data on recently released paroled men who are homeless (N=157), residing in a residential drug treatment program, and enrolled in a longitudinal study to examine personal, developmental, and social correlates of parolees who are homeless and who have committed serious violent offenses. Having experienced childhood sexual abuse, poor parental relationships, and early-onset incarceration (prior to 21 years of age) were important correlates of serious violent crimes. These findings highlight the need for interventions that address offenders' prior adult and childhood victimization and suggest that policies for reentering violent offenders should encompass an understanding of the broader family contexts in which these patterns of maltreatment often occur.

Exploring the reliability and validity of the social-moral awareness test.

BACKGROUND: The aim of the study was to explore the validity of the social-moral awareness test (SMAT) a measure designed for assessing socio-moral rule knowledge and reasoning in people with learning disabilities. Comparisons between Theory of Mind and socio-moral reasoning allowed the exploration of construct validity of the tool. Factor structure, reliability and discriminant validity were also assessed. MATERIALS AND METHODS: Seventy-one participants with mild-moderate learning disabilities completed the two scales of the SMAT and two False Belief Tasks for Theory of Mind. RESULTS: Reliability of the SMAT was very good, and the scales were shown to be uni-dimensional in factor structure. There was a significant positive relationship between Theory of Mind and both SMAT scales. CONCLUSIONS: There is early evidence of the construct validity and reliability of the SMAT. Further assessment of the validity of the SMAT will be required.

Incidence and Visual Outcomes of Endophthalmitis After Intravitreal Injection of Dexamethasone Implant vs Ranibizumab.

Purpose: To compare the incidence and visual outcomes of endophthalmitis after injection of an intravitreal dexamethasone implant and injection of intravitreal ranibizumab. Methods: This retrospective cohort study assessed endophthalmitis in eyes receiving an intravitreal injection of a 0.7 mg dexamethasone implant (DEX group), 0.5 mg ranibizumab (R5 group), or 0.3 mg ranibizumab (R3 group) between January 1, 2016, and May 31, 2018, at 2 large retina practices in the United States. Results: Suspected endophthalmitis occurred in 5 eyes after 4973 DEX injections, 43 eyes after 163 974 R5 injections, and 6 eyes after 18 954 R3 injections. Suspected endophthalmitis was significantly more common in the DEX group (1/995) than in the R5 group (1/3813) (P = .008) but not than in the R3 group (1/3159) (P = .10). Visual acuity outcomes were similar in the 3 groups. Conclusions: Suspected endophthalmitis might be more common after 0.7 mg dexamethasone injections than after 0.5 mg ranibizumab injections. Culture-positive endophthalmitis rates were similar across all 3 medications.

Impact of prison status on HIV-related risk behaviors.

Baseline data were collected to evaluate the effectiveness of interventions on completion of the hepatitis A and B vaccine series among 664 sheltered and street-based homeless adults who were: (a) homeless; (b) recently (<1 year) discharged from prison; (c) discharged 1 year or more; and (d) never incarcerated. Group differences at baseline were assessed for socio-demographic characteristics, drug and alcohol use, sexual activity, mental health and public assistance. More than one-third of homeless persons (38%) reported prison time and 16% of the sample had been recently discharged from prison. Almost half of persons who were discharged from prison at least 1 year ago reported daily use of drugs and alcohol over the past 6 months compared to about 1 in 5 among those who were recently released from prison. As risk for HCV and HIV co-infection continues among homeless ex-offenders, HIV/HCV prevention efforts are needed for this population.

Differentiation of human ES and Parkinson's disease iPS cells into ventral midbrain dopaminergic neurons requires a high activity form of SHH, FGF8a and specific regionalization by retinoic acid.

The cardinal motor symptoms of Parkinson's disease (PD) are caused by the vulnerability to dysfunction and degeneration of ventral midbrain (VM) dopaminergic (DA) neurons. A major limitation for experimental studies of current ES/iPS cell differentiation protocols is the lack of VM DA neurons with a stable phenotype as defined by an expression marker code of FOXA2/TH/ß-tubulin. Here we demonstrate a combination of three modifications that were required to produce VM DA neurons. Firstly, early and specific exposure to 10(-)(8)M (low dose) retinoic acid improved the regional identity of neural progenitor cells derived from human ES cells, PD or healthy subject-specific iPS cells. Secondly, a high activity form of human sonic hedgehog established a sizeable FOXA2(+) neural progenitor cell population in vitro. Thirdly, early exposure to FGF8a, rather than Fgf8b, and WNT1 was required for robust differentiation of the FOXA2(+) floor plate-like human neural progenitor cells into FOXA2(+) DA neurons. FOXA2(+) DA neurons were also generated when this protocol was adapted to feeder-free conditions. In summary, this new human ES and iPS cell differentiation protocol using FGF8a, WNT1, low dose retinoic acid and a high activity form of SHH can generate human VM DA neurons that are required for relevant new bioassays, drug discovery and cell based therapies for PD.

Correlates of depressive symptoms among homeless men on parole.

This study describes correlates of high levels of depressive symptoms among recently paroled men in Los Angeles who reside in a community substance abuse treatment program and report homelessness. Cross-sectional data were obtained from male residents who were released on parole within the last 30 days (N =157) to assess parental relationship, self-esteem, social support, coping behaviors, drug and alcohol use behaviors, depressive symptoms, and sociodemographic information. Results indicated that 40% of the participants were classified as experiencing high levels of depressive symptoms (CES-D ≥ 10). Results of a logistic regression analysis showed that the following were predictors of depressive symptoms (p <.05): physical abuse in childhood, non-residential alcohol treatment, violent behaviors, low self-esteem, and disengagement coping. Being Mexican-American, Mexican, American Indian, or Asian, and not displaying cognitive problems was inversely related to depressive symptoms in the final model (B =-2.39, p <.05). Findings support proper use of both prison and community assessment services to at-risk individuals eligible for parole to increase self-esteem and coping.

Current management strategies for atypical macular holes.

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 µm should undergo internal limiting membrane (ILM) peel. For MH ≥400 µm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 µm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Vitrectomy for Symptomatic Asteroid Hyalosis.

Purpose: Acute vision loss may accompany complete or partial posterior vitreous separation in asteroid hyalosis (AH), and pars plana vitrectomy may resolve these symptoms. Methods: Six individuals with AH and acute vision loss associated with diagnosed posterior vitreous separation were treated with pars plana vitrectomy, and visual acuity (VA) recovery was monitored for 3 months. Results: The study patients' preoperative VA ranged from 20/25 to 20/2500 (mean, 20/150; logMAR, 0.88). The average decrease in VA with anterior progression of the hyaloid was logMAR 0.70. Following surgical clearance of the asteroid bodies, VA returned to baseline within 1 month following vitrectomy in 2 eyes, and within 3 months in all eyes. Final VA was 20/20 to 20/200 (mean, 20/35; logMAR, 0.24). Conclusions: Patients with AH may present with acute onset of severe vision loss in association with posterior vitreous separation. Vitrectomy may be curative and restore vision.

Optical Coherence Tomography Angiography Findings in Patients With Acute Syphilitic Posterior Placoid Chorioretinopathy.

Purpose: Acute syphilitic posterior placoid chorioretinopathy (ASPPC) is an uncommon and distinct manifestation of ocular syphilis necessitating immediate treatment. ASPPC is attributed to disruption of the choriocapillaris, retinal pigment epithelium, and photoreceptors. Optical coherence tomography angiography (OCTA) can evaluate choriocapillaris vascular flow and may provide further information about ASPPC's disease process. Methods: OCTA images from 7 eyes of 4 patients with ASPPC were compared before and after treatment when available. Results: All eyes demonstrated increased choriocapillaris vascular flow voids in the distribution of the ASPPC lesions at initial testing. Following treatment, decreased placoid lesion size was associated with decreased flow voids on OCTA along with improved ellipsoid zone integrity in 2 patients. Conclusions: Disruption of choriocapillaris vascular flow in ASPPC that causes outer retinal changes can improve following treatment as suggested by OCTA imaging. Some cases may continue to demonstrate decreased flow even after appropriate therapy.

Paraneoplastic ocular sarcoidosis in the setting of recurrent rectal carcinoid tumor diagnosed by F18-fluorodeoxyglucose PET CT.

PURPOSE: Nuclear medicine imaging can provide a noninvasive means of distinguishing inflammatory mass lesions from oncologic intraocular tumors. OBSERVATION: We report a case of paraneoplastic ocular sarcoidosis with choroidal mass lesions that was initially concerning for choroidal metastasis of a primary carcinoid tumor. PET CT was utilized with two different tracers to characterize the choroidal mass as being FDG-avid, consistent with a sarcoid-like lesion, and lacking the Gallium (Ga-68) DOTATAE uptake of carcinoid tumor metastases. CONCLUSIONS AND IMPORTANCE: Functional imaging is valuable to distinguish clinically similar inflammatory verses oncologic intraocular pathology.

Retinal nerve fiber layer changes based on historic CD4 nadir among HIV positive patients undergoing glaucoma evaluation.

AIM: To determine relationships between retinal nerve fiber layer (RNFL) thickness and nadir CD4 cell count in human immunodeficiency virus (HIV) positive patients evaluated for glaucoma suspicion. METHODS: Data were reviewed for 329 HIV positive patients evaluated for glaucoma suspicion. High-definition optical coherence tomography (OCT) RNFL measurements were obtained at least 6mo apart. Analyses were performed to identify relationships between nadir CD4 count and RNFL thickness. RESULTS: Totally 110 eyes of 55 patients met inclusion criteria, of which 46 eyes were from subjects with nadir CD4<200 cells/mm3 and 64 had nadir CD4≥200 cells/mm3. Patients with nadir CD4<200 cells/mm3 had significantly thicker superior (119.7±18.6 µm) and temporal (63.8±11.7 µm) quadrants at time of initial OCT compared to the superior (112.8±16.8 µm, P=0.048) and temporal (57.1±11.9 µm, P=0.004) quadrants of patients with higher nadir CD4. This trend toward thicker RNFL among subjects with lower nadir CD4 cell counts persisted at the time of follow up OCT where participants with nadir CD4<200 cells/mm3 showed average RNFL thickness in the superior and temporal quadrants of 117.9±18.3 µm and 63.8±12.8 µm, respectively, compared to a superior thickness of 110.5±16.9 µm (P=0.034) and temporal thickness of 57.3±11.6 µm (P=0.007) among those with higher nadir CD4. CONCLUSION: Patients with lower nadir CD4 cell counts have thicker RNFL in the superior and temporal quadrants compared to those with higher nadir CD4 counts. RNFL thickness in HIV positive patients may be affected by historic HIV disease control and should be considered when evaluating HIV positive patients for glaucoma.

Longitudinal Examination of Fellow-Eye Vascular Anomalies in Coats' Disease With Widefield Fluorescein Angiography: A Multicenter Study.

BACKGROUND AND OBJECTIVE: Retinovascular anomalies in the fellow eyes of patients with Coats' disease have been described, but the clinical significance is unknown, as well as whether these lesions progress over time. PATIENTS AND METHODS: This is an international, multicenter, retrospective, observational cohort study of fellow-eye abnormalities on widefield fluorescein angiography in patients with Coats' disease. RESULTS: Three hundred fifty eyes of 175 patients with Coats' disease were analyzed. A total of 33 patients (18.8%) demonstrated abnormal fellow-eye findings: 14 (42.4%) telangiectasias, 18 (54.5%) aneurysms, six (18.2%) segmental non-perfusion, six (18.2%) leakage, and two (6.0%) vascular tortuosity. All eyes were asymptomatic, and none of the lesions progressed over time. There was no association between fellow-eye findings with severity of Coats' disease (P = .16), patient age (P = .16), or presence of systemic vascular disease (P = .16). CONCLUSIONS: The vascular abnormalities in fellow eyes of patients with Coats' disease did not progress over time. Observation is a reasonable initial management strategy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:221-227.].

Arabidopsis thaliana leaves with altered chloroplast numbers and chloroplast movement exhibit impaired adjustments to both low and high light.

The effects of chloroplast number and size on the capacity for blue light-dependent chloroplast movement, the ability to increase light absorption under low light, and the susceptibility to photoinhibition were investigated in Arabidopsis thaliana. Leaves of wild-type and chloroplast number mutants with mean chloroplast numbers ranging from 120 to two per mesophyll cell were analysed. Chloroplast movement was monitored as changes in light transmission through the leaves. Light transmission was used as an indicator of the ability of leaves to optimize light absorption. The ability of leaves to deal with 3 h of high light stress at 10 degrees C and their capacity to recover in low light was determined by measuring photochemical efficiencies of PSII using chlorophyll a fluorescence. Chloroplast movement was comparable in leaves ranging in chloroplast numbers from 120 to 30 per mesophyll cell: the final light transmission levels after exposure to 0.1 (accumulation response) and 100 micromol photons m(-2) s(-1) (avoidance response) were indistinguishable, the chloroplasts responded quickly to small increases in light intensity and the kinetics of movement were similar. However, when chloroplast numbers per mesophyll cell decreased to 18 or below, the accumulation response was significantly reduced. The avoidance response was only impaired in mutants with nine or fewer chloroplasts, both in terms of final transmission levels and the speed of movement. Only mutants lacking both blue light receptors (phot1/phot2) or those with drastically reduced chloroplast numbers and severely impacted avoidance responses showed a reduced ability to recover from high light stress.