Reoperations for Complications Within 90 Days After Glaucoma Surgery.

OBJECTIVE: To describe reoperations in the operating room for complications encountered within 90 days after glaucoma surgery at a single institution over a 2-year period. DESIGN: Retrospective case series. SUBJECTS: Adult patients who have undergone glaucoma surgery including a tube shunt, trabeculectomy with mitomycin C, trabectome, or transcleral cyclophotocoagulation from June 1, 2015 to August 30, 2017 at a single institution. METHODS: These patients were then examined for postoperative complications that required reoperations within the first 90 days including revision of the tube shunt, revision of the trabeculectomy, drainage of the choroidal, or placement of a tube shunt. MAIN OUTCOME MEASURES: Percentage of reoperations for complications within the first 90 days after glaucoma surgery and surgical indications for these reoperations. RESULTS: A total of 622 glaucoma procedures were performed on 600 eyes in 525 patients over a 2-year period from June 1, 2015 to June 30, 2017 by 4 glaucoma surgeons at a single institution. Of these, 275 (44%) were trabeculectomy with mitomycin C, 253 (41%) were the placement of a tube shunt, 33 (5%) were cyclophotocoagulation, and 61 (10%) were trabectome procedures. Postoperative complications requiring reoperations within 90 days developed in 15 patients (2.4%) overall including 7 patients (2.5%) in the trabeculectomy with mitomycin C group and 8 patients (3.1%) in the tube shunt group. Five patients developed bleb leaks, 3 patients developed serous choroidal effusions, 3 patients had tube exposure, 1 patient had tube retraction, 1 patient had persistent iritis from iris touching the tube, and 1 had encapsulation around the tube. The rate of reoperation for complications was similar between the tube group and the trabeculectomy group (P=0.67, χ test). There were no complications requiring reoperations in 90 days for transcleral cyclophotocoagulation or trabectome. CONCLUSIONS: Early postoperative complications requiring reoperations within the first 90 days after glaucoma surgery were low and comparable with previous studies. Common indications for reoperation within 90 days include wound leak and tube shunt-related issues.

Evaluation of a Deep Learning System For Identifying Glaucomatous Optic Neuropathy Based on Color Fundus Photographs.

PRECIS: Pegasus outperformed 5 of the 6 ophthalmologists in terms of diagnostic performance, and there was no statistically significant difference between the deep learning system and the "best case" consensus between the ophthalmologists. The agreement between Pegasus and gold standard was 0.715, whereas the highest ophthalmologist agreement with the gold standard was 0.613. Furthermore, the high sensitivity of Pegasus makes it a valuable tool for screening patients with glaucomatous optic neuropathy. PURPOSE: The purpose of this study was to evaluate the performance of a deep learning system for the identification of glaucomatous optic neuropathy. MATERIALS AND METHODS: Six ophthalmologists and the deep learning system, Pegasus, graded 110 color fundus photographs in this retrospective single-center study. Patient images were randomly sampled from the Singapore Malay Eye Study. Ophthalmologists and Pegasus were compared with each other and to the original clinical diagnosis given by the Singapore Malay Eye Study, which was defined as the gold standard. Pegasus' performance was compared with the "best case" consensus scenario, which was the combination of ophthalmologists whose consensus opinion most closely matched the gold standard. The performance of the ophthalmologists and Pegasus, at the binary classification of nonglaucoma versus glaucoma from fundus photographs, was assessed in terms of sensitivity, specificity and the area under the receiver operating characteristic curve (AUROC), and the intraobserver and interobserver agreements were determined. RESULTS: Pegasus achieved an AUROC of 92.6% compared with ophthalmologist AUROCs that ranged from 69.6% to 84.9% and the "best case" consensus scenario AUROC of 89.1%. Pegasus had a sensitivity of 83.7% and a specificity of 88.2%, whereas the ophthalmologists' sensitivity ranged from 61.3% to 81.6% and specificity ranged from 80.0% to 94.1%. The agreement between Pegasus and gold standard was 0.715, whereas the highest ophthalmologist agreement with the gold standard was 0.613. Intraobserver agreement ranged from 0.62 to 0.97 for ophthalmologists and was perfect (1.00) for Pegasus. The deep learning system took ∼10% of the time of the ophthalmologists in determining classification. CONCLUSIONS: Pegasus outperformed 5 of the 6 ophthalmologists in terms of diagnostic performance, and there was no statistically significant difference between the deep learning system and the "best case" consensus between the ophthalmologists. The high sensitivity of Pegasus makes it a valuable tool for screening patients with glaucomatous optic neuropathy. Future work will extend this study to a larger sample of patients.

Valve proteoglycan content and glycosaminoglycan fine structure are unique to microstructure, mechanical load and age: Relevance to an age-specific tissue-engineered heart valve.

This study characterized valve proteoglycan and glycosaminoglycan composition during development and aging. This knowledge is important for the development of age-specific tissue-engineered heart valves as well as treatments for age-specific valvulopathies. Aortic valves and mitral valves from first-third trimester, 6-week, 6-month and 6-year-old pigs were examined using immunohistochemistry for versican, biglycan, decorin and hyaluronan, as well as elastin and fibrillin. The fine structure of glycosaminoglycans was examined by fluorophore-assisted carbohydrate electrophoresis. Decorin expression was strongest in the 6-year-old valves, particularly in the aortic valve spongiosa. The quantity of iduronate was also highest in the 6-year-old valves. The central tensile-loading region of the anterior mitral leaflet demonstrated reduced glycosaminoglycan content, chain length and hydration and a larger fraction of 4-sulfated iduronate and lower fraction of 6-sulfation. With age, the anterior leaflet center showed a further increase in 4-sulfated iduronate and decrease in 6-sulfation. In contrast, the anterior leaflet free edge showed decreased iduronate and 4-sulfated glucuronate content with age. The young aortic valve was similar to the mitral valve free edge with a higher concentration of glycosaminoglycans and 6-rather than 4-sulfation, but aged to resemble the mitral anterior leaflet center, with an increase in 4-sulfated iduronate content and a decrease in the 6-sulfation fraction. Elastin and fibrillin often co-localized with the proteoglycans studied, but elastin co-localized most specifically with versican. In conclusion, composition and fine structure changes in valve proteoglycans and glycosaminoglycans with age are complex and distinct within valve type, histological layers and regions of different mechanical loading.

What's in a name?

A 51-year-old man with rheumatoid arthritis and diabetes mellitus presented with new onset left-sided hemiparesis, left-sided neglect, and left-sided incongruous, denser inferiorly, homonymous hemianopsia. Magnetic resonance image of the brain showed prominent swelling of the right frontal, parietal, and occipital lobes greater than on the left with significant change in the fluid-attenuated inversion recovery signal in the gray matter. Perinuclear antineutrophil cytoplasmic antibodies titers were elevated, and skin biopsy demonstrating leukocytoclastic vasculitis. He showed marked clinical and radiographic improvement in association with recovery of vascular abnormalities after the initiation of prednisone, pulse therapy with methylprednisolone, and methotrexate. Clinicians should be aware of the possibility of neuro-ophthalmic manifestations of rheumatoid arthritis, including rheumatoid arthritis-related vasculitis causing homonymous hemianopsia.

Corneal Sensitivity in Tear Dysfunction and its Correlation With Clinical Parameters and Blink Rate.

PURPOSE: To compare corneal sensitivity in tear dysfunction due to a variety of causes using contact and noncontact esthesiometers and to evaluate correlations between corneal sensitivity, blink rate, and clinical parameters. DESIGN: Comparative observational case series. METHODS: Ten normal and 33 subjects with tear dysfunction (meibomian gland disease [n = 11], aqueous tear deficiency [n = 10]-without (n = 7) and with (n = 3) Sjögren syndrome (SS)-and conjunctivochalasis [n = 12]) were evaluated. Corneal sensitivity was measured with Cochet-Bonnet and air jet esthesiometers and blink rate by electromyography. Eye irritation symptoms, tear meniscus height, tear break-up time (TBUT), and corneal and conjunctival dye staining were measured. Between-group means were compared and correlations calculated. RESULTS: Compared with control (Cochet-Bonnet 5.45 mm, air esthesiometer 3.62 mg), mean sensory thresholds were significantly higher in aqueous tear deficiency using either Cochet-Bonnet (3.6 mm; P = .003) or air (11.7 mg; P = .046) esthesiometers, but were not significantly different in the other groups. Reduced corneal sensitivity significantly correlated with more rapid TBUT and blink rate and greater irritation and ocular surface dye staining with 1 or both esthesiometers. Mean blink rates were significantly higher in both aqueous tear deficiency and conjunctivochalasis compared with control. Among all subjects, blink rate positively correlated with ocular surface staining and irritation and inversely correlated with TBUT. CONCLUSION: Among conditions causing tear dysfunction, reduced corneal sensitivity is associated with greater irritation, tear instability, ocular surface disease, and blink rate. Rapid blinking is associated with worse ocular surface disease and tear stability.