Incidence of emergence agitation in children undergoing sevoflurane anesthesia compared to isoflurane anesthesia: An updated systematic review and meta-analysis.

BACKGROUND: Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with other postoperative complications. Sevoflurane has been associated with emergence agitation, potentially due to low tissue solubility and therefore speed of emergence. Prior meta-analyses comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics did not demonstrate a statistically significant difference. Given the publication of additional relevant studies not included in prior meta-analyses as well as improved diagnosis of emergence agitation, we aim to perform an updated, comprehensive meta-analysis comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics in children. METHODS: We conducted an updated systematic review and meta-analysis of clinical trials comparing sevoflurane to isoflurane in children <18 years of age, reporting emergence agitation as an outcome, published before July 2023 using databases and registers. Our primary outcome was the incidence of emergence agitation. Secondary outcomes were time to extubation, awakening time, and length of stay in the postanesthetic care unit. We assessed the risk of bias using the Cochrane Risk of Bias tool version 2. We pooled the effect size for the outcomes using the fixed effects model if we had low heterogeneity, otherwise, we used a random-effects model. RESULTS: Eight randomized controlled trials (523 children) were included in the final analysis. The incidence of emergence agitation after isoflurane was significantly lower compared to sevoflurane (risk ratio: 0.62 (95% CI: [0.46-0.83]; I2 = 40.01%, p < .001)). Time to extubation, awakening times, and postanesthetic care unit duration were not significantly different. The protective effect of isoflurane compared to sevoflurane remained significant in subgroups of patients who received premedication or intraoperative systemic analgesics (risk ratios: (0.48 [0.28-0.82]; I2 = 60.78%, p = .01), (0.52 [0.37-0.75]; I2 = 0.00%, p < .001), respectively). CONCLUSION: The risk of emergence agitation in children after maintenance anesthesia with sevoflurane is significantly greater than with isoflurane; we did not find evidence of prolonged emergence or postanesthetic length of stay. When possible, isoflurane should be considered for maintenance anesthesia over sevoflurane in patients at high risk of emergence agitation.

Association of Type of Oral Anticoagulant Dispensed With Adverse Clinical Outcomes in Patients Extending Anticoagulation Therapy Beyond 90 Days After Hospitalization for Venous Thromboembolism.

Importance: Guidelines for managing venous thromboembolism (VTE) recommend at least 90 days of therapy with oral anticoagulants. Limited evidence exists about the optimal drug for continuing therapy beyond 90 days. Objective: To compare having prescriptions dispensed for apixaban, rivaroxaban, or warfarin after an initial 90 days of anticoagulation therapy for the outcomes of hospitalization for recurrent VTE, major bleeding, and death. Design, Setting, and Participants: This exploratory retrospective cohort study used data from fee-for-service Medicare (2009-2017) and from 2 commercial health insurance (2004-2018) databases and included 64 642 adults who initiated oral anticoagulation following hospitalization discharge for VTE and continued treatment beyond 90 days. Exposures: Apixaban, rivaroxaban, or warfarin prescribed after an initial 90-day treatment for VTE. Main Outcomes and Measures: Primary outcomes included hospitalization for recurrent VTE and hospitalization for major bleeding. Analyses were adjusted using propensity score weighting. Patients were followed up from the end of the initial 90-day treatment episode until treatment cessation, outcome, death, disenrollment, or end of available data. Weighted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs. Results: The study included 9167 patients prescribed apixaban (mean [SD] age, 71 [14] years; 5491 [59.9%] women), 12 468 patients prescribed rivaroxaban (mean [SD] age, 69 [14] years; 7067 [56.7%] women), and 43 007 patients prescribed warfarin (mean [SD] age, 70 [15] years; 25 404 [59.1%] women). The median (IQR) follow-up was 109 (59-228) days for recurrent VTE and 108 (58-226) days for major bleeding outcome. After propensity score weighting, the incidence rate of hospitalization for recurrent VTE was significantly lower for apixaban compared with warfarin (9.8 vs 13.5 per 1000 person-years; HR, 0.69 [95% CI, 0.49-0.99]), but the incidence rates were not significantly different between apixaban and rivaroxaban (9.8 vs 11.6 per 1000 person-years; HR, 0.80 [95% CI, 0.53-1.19]) or rivaroxaban and warfarin (HR, 0.87 [95% CI, 0.65-1.16]). Rates of hospitalization for major bleeding were 44.4 per 1000 person-years for apixaban, 50.0 per 1000 person-years for rivaroxaban, and 47.1 per 1000 person-years for warfarin, yielding HRs of 0.92 (95% CI, 0.78-1.09) for apixaban vs warfarin, 0.86 (95% CI, 0.71-1.04) for apixaban vs rivaroxaban, and 1.07 (95% CI, 0.93-1.24) for rivaroxaban vs warfarin. Conclusions and Relevance: In this exploratory analysis of patients prescribed extended-duration oral anticoagulation therapy after hospitalization for VTE, prescription dispenses for apixaban beyond 90 days, compared with warfarin beyond 90 days, were significantly associated with a modestly lower rate of hospitalization for recurrent VTE, but no significant difference in rate of hospitalization for major bleeding. There were no significant differences for comparisons of apixaban vs rivaroxaban or rivaroxaban vs warfarin.

Vitreoretinal Complications and Outcomes in 92 Eyes Undergoing Surgery for Modified Osteo-Odonto-Keratoprosthesis: A 10-Year Review.

PURPOSE: To analyze vitreoretinal (VR) complications and treatment outcomes in eyes undergoing modified osteo-odonto-keratoprosthesis (OOKP) surgery. DESIGN: Retrospective case series. PARTICIPANTS: All patients who underwent modified OOKP (mOOKP) surgery at a tertiary eye-care center from March 2003 to February 2013 were included. METHODS: Medical records were reviewed for relevant medical history, best-corrected visual acuity (BCVA), slit-lamp examination, ultrasound scan, oral examination findings, and VR complications. MAIN OUTCOME MEASURES: The BCVA at the last visit. Optimal anatomic outcome was attached retina with a normal intraocular pressure at the last visit. RESULTS: A total of 92 eyes of 90 patients were included. Indications for OOKP included Stevens-Johnson syndrome (n = 53), chemical injury (n = 36), and ocular cicatricial pemphigoid (n = 3). A total of 41 eyes of 39 patients developed VR complications, including vitritis (n = 21), retinal detachment (RD) (n = 12; primary RD = 5), retroprosthetic membrane (RPM) (n = 10; primary RPM = 2), endophthalmitis (n = 8), vitreous hemorrhage (VH) (n = 5; primary VH = 1), serous choroidal detachment (n = 5), hemorrhagic choroidal detachment (n = 2), and leak-related hypotony (n = 1). Mean interval from mOOKP surgery to occurrence of VR complication(s) was 43.8 months (median, 41.9 months; range, 0.2-95.5 months). After treatment of VR complication, visual improvement was seen in 17 eyes (42%) (mean improvement = 1.2 logarithm of the minimum angle of resolution [logMAR]; median, 0.8 logMAR; range, 0.1-2.5 logMAR), visual decline in 7 eyes (14%) (mean decline in BCVA = 0.6 logMAR; median, 0.4 logMAR; range, 0.3-1.8 logMAR), and no change in BCVA in 17 eyes (42%). However, BCVA ≥6/60 was retained in 19 eyes and ≥6/18 was retained in 9 eyes after final VR treatment. CONCLUSIONS: Vitreoretinal complications constitute a significant cause of visual morbidity in eyes undergoing mOOKP surgery and pose a challenging situation to manage. However, appropriate and timely intervention can achieve encouraging results.

VITREORETINAL COMPLICATIONS IN EYES WITH BOSTON KERATOPROSTHESIS TYPE I.

PURPOSE: To describe the spectrum of vitreoretinal complications in eyes with Boston keratoprosthesis type I and evaluate the treatment outcomes. METHODS: This was a retrospective interventional case series of 23 of 45 eyes that underwent Boston keratoprosthesis from April 2003 to December 2013 and developed vitreoretinal complications. Types of vitreoretinal complications, surgical techniques, and anatomical and visual outcomes were analyzed. RESULTS: Vitreoretinal complications in eyes with Boston keratoprosthesis included retroprosthetic membranes (n = 11), retinal detachment (n = 6), endophthalmitis (n = 4), epiretinal membrane (n = 4), vitreous hemorrhage (n = 2), and choroidal detachment (n = 1). Twenty of 23 eyes (87%) underwent surgical intervention. Retinal reattachment was achieved in 5 eyes (83%) with significant visual improvement in 3 (50%). Mean preoperative visual acuity improved from 1.84 ± 0.89 logMAR to 1.5 ± 0.87 logMAR (P = 0.01) at the last follow-up. Mean 1.4 surgical procedures were performed per eye. Mean follow-up was 28 months (median: 28 months, range: 5-57 months). CONCLUSION: Retroprosthetic membrane and retinal detachment are most common vitreoretinal complications in eyes with Boston keratoprosthesis. Vitreoretinal complications can be managed by appropriate intervention in such eyes with encouraging anatomical and functional results.

Bone augmentation of the osteo-odonto alveolar lamina in MOOKP--will it delay laminar resorption?

PURPOSE: We aimed to describe a new technique and analyse the early outcomes of augmenting the canine tooth using a mandibular bone graft in an attempt to delay or retard the process of laminar resorption following the modified osteo odonto keratoprosthesis (MOOKP) procedure. DESIGN: This was a retrospective case series. PATIENTS AND METHODS: Eyes that underwent the bone augmentation procedure between December 2012 and February 2014 were retrospectively analysed. The procedure, performed by the oromaxillofacial surgeon, involved securing a mandibular bone graft beneath the periosteum on the labial aspect of the canine tooth chosen to be harvested for the MOOKP procedure. This procedure was performed simultaneously with the Stage 1 A of the MOOKP. Three months later, the tooth was harvested and fashioned into the osteo-odonto alveolar lamina similar to the method described in the Rome-Vienna Protocol. RESULTS: The bone augmentation procedure was performed in 11 eyes (five SJS/ six chemical injuries). The mean follow-up after Stage 2 of MOOKP procedure in these eyes was 7.45 months (2 to 20 months). Complications noted were peripheral laminar exposure (three eyes-SJS) and bone graft exposure and necrosis in the mouth (nine-SJS). No evidence of clinical laminar resorption was noted in any of the eyes. CONCLUSION: Laminar resorption in MOOKP can lead to vision and globe threatening complications due to the consequent cylinder instability and chances of extrusion. Augmenting the bone on the labial aspect of the canine tooth might have a role to play in delaying or preventing laminar resorption.

Hepatitis C virus core and NS3 antigens induced conjunctival inflammation via toll-like receptor-mediated signaling.

PURPOSE: Dry eye condition is an extrahepatic manifestation associated with chronic hepatitis C virus (HCV) infection. Since conjunctival inflammation can contribute to the dry eye condition, in the present study we analyzed the conjunctival inflammatory response to HCV core and NS3 proteins. METHODS: We used primary human conjunctival fibroblasts for our study. Cytokines were measured with enzyme-linked immunosorbent assay (ELISA). Toll-like receptor (TLR) and cell adhesion molecule gene expression patterns were analyzed with semiquantitative reverse transcription (RT)-PCR. Immunofluorescence staining was performed for the MyD88, nuclear factor-kappa B (NF-kB), and inducible nitric oxide synthase (iNOS) proteins. Nitric oxide (NO) was measured with the Griess assay; terminal deoxynucleotidyl transferase-mediated uridine 5'-triphosphate-biotin nick end labeling (TUNEL) and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assays were performed for apoptosis and cell viability, respectively. RESULTS: When exposed to the HCV core and NS3 proteins, the conjunctival fibroblasts secreted interleukin-8 (IL-8), IL-6, tumor necrosis factor-alpha (TNF-α), and IL-10 in a dose-dependent manner. Various TLRs were involved in the innate immune response via MyD88 signaling without NF-kB involvement. The gene expression of cell adhesion molecules such as CD44 and ICAM-1 was upregulated, and the cells secreted NO via iNOS. As the sum of these stress responses, the cells underwent apoptosis, which eventually lead to cell death. CONCLUSIONS: HCV core and NS3 proteins induced conjunctival inflammation that may form the pathogenesis of dry eye condition.

Comprehensive approach to ocular consequences of Stevens Johnson Syndrome - the aftermath of a systemic condition.

BACKGROUND: Stevens Johnson Syndrome (SJS) can lead to end stage corneal blindness. This study describes the comprehensive treatment measures and their outcomes in the management of ocular sequelae and complications of SJS. METHODS: Four hundred sixty-four eyes of 232 patients of SJS who underwent surgical intervention (punctal cautery, mucus membrane grafting for lid margin keratinisation, fornix reconstructive procedures, tectonic procedures, keratoplasty and keratoprosthesis) were studied. It was a non-comparative, retrospective, interventional case series. The primary outcome was the change in the best corrected visual acuity (BCVA). Secondary outcome measures included an improvement in the ocular surface status as indicated by corneal epithelial fluorescein staining and Schirmer's I strip wetting. RESULTS: The BCVA and the ocular surface status improved and/or stabilized in > 70 % of eyes following punctal cautery (n = 160) and > 80 % of eyes following lid margin mucus membrane grafting (n = 238). BCVA improved in 50 % of eyes following fornix reconstructive procedures (n = 24) with COMET (n = 6), in 63.9 % eyes with the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) lens (n = 36), in 81.8 % of eyes after cataract surgery (n = 22). A BCVA of ≥20/200 was achieved in 72.34 % of eyes following keratoprostheses procedures (n = 47). The mean duration of follow up was 53.3 ± 15.2 months. CONCLUSION: The ocular sequelae of Stevens Johnson Syndrome can be blinding. They need to be identified and addressed early to retard the continued deterioration of the ocular surface. Our study aims to highlight the problem as well as the importance of comprehensive measures in the management of this potentially blinding disorder.

Structural & functional rehabilitation in eyes with lamina resorption following MOOKP--can the lamina be salvaged?

PURPOSE: To describe a new technique and analyze the outcome of procedures performed for anatomic and functional rehabilitation in eyes with lamina resorption following the modified osteo-odonto keratoprosthesis (MOOKP) procedure. DESIGN: Retrospective case series. PATIENTS & METHODS: Eighteen eyes were noted to have lamina resorption of the 85 eyes that underwent the MOOKP surgery over the last 10 years. Further intervention to salvage the globe, and therefore the visual potential, was possible in only 11 eyes, of which two are yet to undergo further intervention. Two patients who had undergone the procedure elsewhere also presented to our centre with evidence of resorption. In all, 11 eyes (nine operated at our centre, two operated elsewhere) were included in this study. Bone morphogenetic protein (BMP) was used alone or along with mandibular cancellous bone within the fibrovascular capsule of the osteo-odonto alveolar lamina, in an effort to prevent further resorption and promote bone generation in areas of resorption in ten eyes. In three of these eyes, there was a continued progression of resorption requiring lamina removal. In these three eyes and another eye with extrusion of the cylinder from the eye, the Lucia Type 2 keratoprosthesis was performed for visual rehabilitation (four eyes). RESULTS: The BMP procedure was performed in ten eyes. Continued resorption with need for further rehabilitative surgery in the form of Lucia Type 2 Kpro was required in three of these eyes. Of the four patients who had the Lucia Type 2 Kpro, visual acuity improved to better than 20/200 in three eyes over a mean follow-up period of 3 months. Of the remaining seven eyes that had the BMP procedure performed, all have remained stable with respect to anatomic integrity of the lamina and globe, with maintenance of or improvement in pre BMP visual acuity over a mean follow-up of 9.2 months. No other complications of the procedure were noted. CONCLUSION: Resorption of the lamina in MOOKP can be addressed by reinforcing the same with BMP in eyes where the cylinder mobility is not significant, as a means to prolong the longevity of the existing lamina. The Lucia Type 2 Kpro might also have a role to play in the functional rehabilitation of eyes with severe lamina resorption or cylinder extrusion if preparation of a new lamina cannot be performed for various reasons.

Aberration change after scleral lens wear in eyes with pellucid marginal degenerations.

PURPOSE: To investigate the impact of scleral lenses (SLs) on higher-order aberrations (HOAs), corrected distance visual acuity (CDVA), and contrast sensitivity (CS) in pellucid marginal degeneration (PMD) eyes. METHODS: SLs were fitted in 24 eyes diagnosed with PMD. CDVA, CS, and HOAs were measured at baseline and with the lens on the eye. The HOAs were measured using an i-Trace aberrometer. RESULTS: A statistically significant improvement was noted in CDVA ( P < 0.001) with BSS lenses (0.05 ± 0.04) compared to baseline (0.42 ± 0.06). Front surface eccentricity 1 (FSE1) lens provided the best CDVA in most of the eyes. The baseline CS of 1.24 ± 0.74 improved to 1.58 ± 0.48 with SL and reported a statistically significant improvement ( P < 0.001) and a gain of 6 letters. The baseline higher order-root mean square (HO-RMS) was 0.89 ± 0.53 µm, which reduced to 0.38 ± 0.24 µm ( P < 0.001), and RMS coma of 0.45 ± 0.29 µm improved to 0.20 ± 0.12 µm ( P < 0.001). Though there was a marginal reduction from 0.04 ± 0.14 to 0.03 ± 0.07, RMS spherical aberration did not show any statistically significant difference ( P = 0.37). RMS secondary astigmatism reduced from 0.17 ± 0.15 µm to 0.08 ± 0.12 µm ( P = 0.007), and RMS trefoil reduced to 0.13 ± 0.09 µm from 0.64 ± 0.36 µm ( P < 0.001) with SLs and showed statistically significant improvement. CONCLUSION: SLs can be considered an effective option that corrects a significant amount of HOAs and enhances visual performances in PMD eyes.

Scleral lens induced short term corneal changes in eyes with Pellucid Marginal Degeneration.

PURPOSE: To investigate the short-term effect of scleral lens (SL) on corneal curvature and corneal oedema in Pellucid Marginal Degeneration (PMD) eyes. METHODS: Corneal anterior, posterior curvature and corneal thickness were measured in 14 eyes of 14 PMD participants with Schiempflug imaging at different corneal diameters and meridians at baseline and after 6 h of SL wear. RESULTS: There was a significant flattening (up to 0.26 mm) of the anterior corneal curvature noted in the inferotemporal quadrant (from 210 to 255 degree at 2 mm, 8 mm and 10 mm corneal diameter), inferonasal quadrant (from 285 to 345 degree at 6 mm and 8 mm corneal diameter), and inferiorly at 2 mm and 10 mm corneal diameter (p < 0.05). Similarly, posterior corneal curvature showed statistically significant steepening mostly in inferotemporal quadrants (from 195 to 255 degree from 4 mm to 8 mm corneal diameter) and inferonasally at 2 mm and 4 mm corneal diameter (p < 0.05). A statistically significant increase in the corneal thickness noted in different corneal diameters with corneal oedema ranging from 2.10 % to 4.00 % after 6 h of SL wear. A gradual increase in corneal oedema was noted form centre to periphery. The baseline central fluid reservoir thickness (FRT) was 341.07 ± 139.8 which reduced to 276.71 ± 114.32 µm after 6 h of lens wear. No significant correlation was noted between corneal oedema with different parameters like initial and final FRT, change in anterior and posterior corneal curvature, and lens thickness (p > 0.05). CONCLUSIONS: Short-term SL wear induced a clinically acceptable range of corneal oedema. A clinically significant flattening in anterior curvature and minimal steepening in posterior curvature were noted. Practitioners should be careful while measuring corneal parameters in PMD eyes wearing SL, as these alterations can provide false impression of disease progression.

Unique cytokine signature in ocular Stevens-Johnson syndrome non-responders.

PURPOSE: To clinically define a subset of patients with chronic ocular Stevens-Johnson syndrome non-responders (SJS-NR) and analyze their cytokine profile compared to clinical responders (SJS-CR). METHODS: A total of 32 SJS cases (n = 32, 64 eyes) managed over a period of three years were segregated into clinical responders (n = 24, 48 eyes) and non-responders (n = 8, 16 eyes). Cases were determined as non-responders based on persistent, refractory, and non-mechanical inflammation of the conjunctiva. Age- and sex-matched healthy controls (n = 25, 50 eyes) were recruited. Tear specimens collected using Schirmer's strip were profiled for 27 cytokines using an immunoassay-based 27-bioplex array. RESULTS: Tear cytokine profiling revealed 18 cytokines to be differentially expressed in SJS-NR compared to SJS-CR. While PDGF-BB, IL-4, IL-1ß, VEGF, IL-12p70, IFN-γ, IL-9, and IL-1RA were upregulated, GM-CSF, eotaxin, IP-10, IL-10, MCP-1, G-CSF, IL-6, IL-13, and bFGF were downregulated in SJS-NR compared to SJS-CR. The cytokines IL-13, IL-10, and IP-10 were decreased in both SJS-NR and SJS-CR compared to controls. CONCLUSION: The inflammation in SJS-NR continues to worsen despite the correction of mechanical causes, resulting in progressive deterioration of the cornea. The cytokine profile of SJS-NR was remarkably different from that of SJS-CR, indicating a T helper 2-type protective proliferative response and an impaired migratory potential of the conjunctival epithelium. These factors could possibly lead to poor healing of the corneal epithelium in a markedly pro-inflammatory and pro-angiogenic milieu. The top four differentially expressed cytokines, PDGF-BB, IL-4, IL-10, and IL-6, are proposed as potential biomarkers of SJS-NR.

Unraveling the complexity - Insights and interventions of refractory vernal keratoconjunctivitis.

Vernal keratoconjunctivitis (VKC) is a chronic severe ocular allergic inflammation mostly observed in children and young adults. The ocular manifestations are the expression of multifactorial immune mechanisms that generally have a good prognosis, however long-term inflammation may remarkably reduce the visual function due to complications and poor therapeutic responses. Lack of responsiveness to a drug or treatment is relatively common in VKC and it is not only due to corneal involvement, which is considered the main sign of severity. The concept of refractory may be relative to multiple factors including the clinical condition, systemic co-morbidities, previous or concomitant drugs or regiments, compliance, patient's psychological condition or expectations, type of exposome and environmental conditions, doctor's experience and expectations, or timing of clinical evaluation. In this narrative review, the authors propose a definition of refractory VKC based on revised literature and clinical experience and consider potential new treatments for refractory patients and surgical management in case of complications.

Depth, size of infiltrate, and the microbe - The trio that prognosticates the outcome of infective keratitis.

PURPOSE: To analyze the influence of infiltrate size, depth, and organism on the outcome of microbial keratitis. DESIGN: Retrospective comparative study. METHODS: Medical records of patients with infective keratitis, who reported from January 2015 to December 2019 to a tertiary eye care center, were analyzed. Size and depth of ulcer at presentation were the factors used to group patients, and the influence on the outcome of the organism causing it was analyzed. Grouping was as follows: group A: ulcer size <6 mm/anterior to midstromal infiltrate, group B: ulcer < 6 mm/full-thickness infiltrate, group C: ulcer >6 mm/anterior to midstromal infiltrate, group D: ulcer > 6 mm/full-thickness infiltrate. Patients with viral keratitis or unidentified organism were excluded. Response to treatment and best-corrected visual acuity (BCVA) at the final follow-up were the outcome measures. RESULTS: In the study, 1117/6276 patients were included, with 60.8% patients in group A. A significant improvement in visual acuity was noted in groups A/B compared to groups C/D. Group A had the best response to medical management, irrespective of the organism. Higher risk for surgery was noted in group C compared to group B, with group A as the reference. Overall resolution with medical treatment was noted in 70% miscellaneous keratitis, 64.8% bacterial keratitis, 64.3% mixed keratitis, 62.5% acanthamoeba keratitis, 52.6% fungal keratitis, and 12.1% Pythium keratitis. Bacteria and acanthamoeba responded better to medical management than fungal keratitis, whereas Pythium had the highest risk for surgery. CONCLUSION: An interplay between virulence of the organism along with depth and size of the infiltrate determines the outcome of microbial keratitis.

Cryptophthalmos: reconstructive techniques--expanded classification of congenital symblepharon variant.

PURPOSE: To report the varied presentation and management of cryptophthalmos and further categorize grades of the congenital symblepharon variant based on the severity of the defect. METHODS: The records of 34 eyes of 25 patients with cryptophthalmos who sought treatment at the authors' tertiary eye care center over a period of 22 years were analyzed. RESULTS: Of the 34 eyes, 25 belonged to the congenital symblepharon variant, which could distinctively be further classified in medial/mild (4), moderate (9), and severe (11) subgroups and the surgical management for each has been outlined. The associated corneal and facial anomalies have also been highlighted along with their management modalities when indicated. CONCLUSIONS: Although a rare clinical entity, this is the largest series of cryptophthalmos reported so far with a proposed classification scheme for the congenital symblepharon variant.

Management of coexisting bilateral ocular surface disease in xeroderma pigmentosum - sequence and outcomes.

PURPOSE: To report a rare presentation of bilateral, coexisting ocular surface disease in a case of Xeroderma pigmentosum and its successful management. METHODS: Case report. RESULTS: A 21-year-old male with Xeroderma pigmentosum presented with bilateral ocular surface squamous neoplasia (OSSN) along with central guttae in the right eye and corneal decompensation of the left eye. Subsequently, the patient developed dry eyes and lid margin keratinization in both eyes followed by perforation in the left eye. Sequential procedures both medical and surgical, including excision of the tumour, corneal transplantation and mucous membrane grafting addressing each of these ocular surface issues resulted in a successful outcome. There was no recurrence of the tumour over 3 years. Corneal transplantation is preferably done after a minimum of 6 months following excision. Mucous membrane grafting performed for progressive lid margin keratinization resulted in surface stabilization. CONCLUSIONS: In Xeroderma Pigmentosum, multiple ocular surface features can rarely coexist and be bilateral. Periodic evaluation of the surface for tumours, progressive dry eyes and endothelial function is recommended as a part of routine evaluation in Xeroderma pigmentosum. Surface procedures should precede intraocular intervention. Sequential management can result in successful outcomes.

E-PIX: An enhanced grading for acute ocular burns.

An enhanced online and manual grading system, based on the I's and E's, for acute ocular chemical injuries is being proposed. E-PIX is designed to be an online/manual grading system that includes all the parameters that adversely affect the outcome of acute chemical injuries. The importance of addressing the I's and E's in chemical burns cannot be underestimated. These include the need for the documentation and management of epithelial defect (E), intraocular pressure (P) (IOP), ischemia (scleral) (I), and exposure (X) (acronym - E-PIX). Epithelial defect includes that involving the limbus (L), along with conjunctival (C), corneal (K), and tarsal (T). These additional parameters are graded and represented as an annotation along with the limbal grade providing a comprehensive grading for the injury. A manual entry sheet and a freely accessible online grade generator are a part of the system. The proposed enhanced grading offers a final annotation that provides a clear understanding of all factors that can lead to vision-threatening complications ensuring their assessment and hence subsequently their addressal to improve outcomes, if abnormal. The prognostication continues to be based on the grade of limbal involvement. The additional annotations impact prognosis and outcome if not addressed. Including the laterality of injury provides, in addition, a futuristic understanding of available options. The grade generator retains the flexibility to be dynamic with changes reflecting upon the healing process in the acute stage. The proposed system aims to provide primary and tertiary caregivers alike with a uniform grading system.

Bilateral Ocular Rosai-Dorfman Disease Presenting as Diffuse Anterior Scleritis with Multiple Enlarging Epibulbar Masses.

PURPOSE: To report a unique case of extranodal Rosai-Dorfman disease (RDD) presenting as bilateral scleritis, which progressed to multifocal epibulbar masses. METHODS: Retrospective chart review. RESULTS: A 35-year-old Asian man presented with progressive pain and redness in both eyes for 4 months. Examination revealed bilateral diffuse scleral congestion and areas of scleral thinning. The cornea and anterior chamber of each eye were unremarkable. Despite oral corticosteroid and immunosuppressive treatment, scleritis progressed to multifocal epibulbar masses. Tissue biopsy specimens revealed foamy macrophages with histiocytes staining positive for CD68 and S100, confirming a diagnosis of RDD. Systemic evaluation was unremarkable for lymphadenopathy or extranodal involvement. The patient was started on systemic chemotherapy and at last follow up after 1 year, all epibulbar lesions were completely resolved. CONCLUSIONS: Rosai-Dorfman disease can present as bilateral scleritis initially and develop epibulbar masses without any systemic involvement. Biopsy with immunohistochemical analysis can aid in the diagnosis.

Trends in the Use of Oral Anticoagulants for Adults With Venous Thromboembolism in the US, 2010-2020.

Importance: The introduction of direct oral anticoagulants (DOACs) has transformed the treatment of venous thromboembolism (VTE). Large health care databases offer valuable insight into how oral anticoagulants (OACs) are used in clinical practice and may aid in understanding reasons for changes in therapy. Objectives: To evaluate prescribing patterns of OACs for patients with VTE and identify clinical events that precede treatment changes. Design, Setting, and Participants: This retrospective cohort study used data from a public (Medicare fee-for-service) and a commercial (IBM MarketScan) health insurance database on 298 609 patients initiating OACs within 90 days of index VTE hospitalization from January 1, 2009, to December 31, 2020. Statistical analysis was conducted from April to August 2022. Exposures: Warfarin and the DOACs rivaroxaban, apixaban, dabigatran, and edoxaban. Main Outcomes and Measures: Characteristics of patients initiating different OACs, along with trends over time of patients initiating OACs, were compared. Time receiving continuous anticoagulant therapy, patterns of anticoagulant discontinuation (treatment gap of ≥30 days), and treatment switches were assessed. Clinical events in the 30 days preceding treatment modifications were identified. Results: A total of 203 378 individuals with Medicare (mean [SD] age, 76.9 [7.6] years; 122 554 women [60.3%]) and 95 231 with commercial insurance (mean [SD] age, 57.6 [15.8] years; 47 139 women [49.5%]) were included (N = 298 609). Warfarin was the most frequent OAC prescribed (163 044 [54.6%]), followed by rivaroxaban (66 882 [22.3%]) and apixaban (65 997 [22.1%]). The proportion of patients initiating DOACs increased from 0% in 2010 to 86.8% (22 420 of 25 817) in 2019 for patients with Medicare and 92.1% (4012 of 4357) in 2020 for commercially insured patients. Patients with chronic kidney disease were more likely to initiate warfarin (35 561 [11.9%]) or apixaban (16 294 [5.5%]) than rivaroxaban (10 136 [3.4%]), and those with a history of bleeding were more likely to initiate apixaban (5424 [1.8%]) than rivaroxaban (3007 [1.0%]). Overall, patients received persistent OAC treatment for approximately 6 months (Medicare: median, 175 days [IQR, 76-327 days]; commercial insurance: median, 168 days [IQR, 83-279 days]). A total of 33 011 patients (11.1%) switched anticoagulant therapy within a year. Switching to another anticoagulant was preceded most frequently by codes for a VTE diagnostic procedure (27.2% of all switchers [8983 of 33 011]). Conclusions and Relevance: This cohort study using data from 2 US health insurance databases suggests that most patients with VTE continued oral anticoagulant treatment for approximately 6 months. Clinical reasons for modifying anticoagulant therapy were identified in one-third of patients. Identifying reasons for treatment modification is crucial for generating valid evidence on drug safety and effectiveness.

Possible Synergistic Role of Cryo-Alcohol Therapy in Infectious Scleritis-Scope and Rationale for Expanding Indications and Review of the Literature.

PURPOSE: The purpose of this study was to highlight the use of topical ethanol as an adjunct to cryotherapy, termed cryo-alcohol therapy, in the management of fungal/acanthamoeba scleritis along with a review of the literature. METHOD: Retrospective interventional case reports of fungal and acanthamoeba scleritis along with a review of the literature. RESULTS: The patient with circumferential necrotic fungal scleritis resolved in 6 weeks achieving a best-corrected visual acuity (BCVA) of 20/20, and the patient with acanthamoeba scleritis is awaiting optical keratoplasty after complete resolution in 8 weeks. The literature review from January 1990 to December 2020 revealed BCVA >20/200 in 50% of the eyes with a mean time to resolution being 4.16 ± 2.13 months in fungal scleritis, with 27.02% and 75% of the eyes requiring evisceration in fungal and acanthamoeba scleritis, respectively. CONCLUSIONS: Cryotherapy is a useful adjunct in managing refractory infectious scleritis, and its efficacy can be enhanced by combining the use of topical ethanol to aid in faster recovery and reduce visual morbidity.

Dry eye module - An application intelligence platform for diagnosing and monitoring dry eye disease.

Dry Eye Module (DEM), a software application, was developed to facilitate the streamlining of dry eye evaluation and documentation, to unify diagnostic jargon, and to analyze data input to generate a dry eye diagnostic report. This diagnostic report generated is based on the current understanding of dry eye diagnostic algorithms (Dry Eye Workshop 2 [DEWS2]/Asia Dry Eye Society [ADES]). Apart from its plausible role in aiding unprecedented multicentric dry eye demographic data collection, the application software can generate a customized referral letter to the rheumatologist, highlighting the salient ophthalmic features to be shared. DEM uses schematic illustrations to depict eyelid, conjunctival, and corneal parameters that impact the ocular surface in dry eyes that can be captured and compared during serial visits. Furthermore, DEM displays a symptom sign trend chart that graphically represents improvement/stability or worsening of the subjective and objective dry eye status. DEM can generate a curated prescription using preloaded advice templates. DEM includes facility for state-of-the-art advanced dry eye diagnostic reporting for super specialty use. The addition of DEM to the dry eye diagnostic armamentarium would help bridge the current unmet needs of dry eye evaluation. These are lack of uniform reporting, lack of multicentric data on a unified platform, the inability to ensure complete evaluation, inability to avoid lacunae during follow-up visits, and the lack of a simple patient-ophthalmologist and an ophthalmologist-rheumatologist interface.