Safety of Concurrent Boston Type I Keratoprosthesis and Glaucoma Drainage Device Implantation.

PURPOSE: To evaluate the safety of concurrent Boston type I keratoprosthesis (KPro) and glaucoma drainage device (GDD) implantation. DESIGN: Retrospective comparative study of a consecutive cohort of patients. SUBJECTS: Patients who underwent KPro implantation by a single surgeon (A.J.A.) with or without 1 concurrent Ahmed GDD (New World Medical, Inc., Rancho Cucamonga, CA) implantation between January 1, 2005, and January 31, 2015, were included. Patients with fewer than 3 months of follow-up or a history of previous KPro implantation were excluded. METHODS: Preoperative, operative, and postoperative data were collected for each procedure. All comparisons were made between KPro procedures performed with or without concurrent GDD implantation. The Fisher exact test (2-tailed) was used to compare proportions, Student t test and Wilcoxon rank-sum test were used to compare means, and the log-rank test was used to compare time-to-outcome events. MAIN OUTCOME MEASURES: The primary outcome was frequency of the composite variable, that is, any serious vision-threatening postoperative complication, which included sterile vitreitis, endophthalmitis, hypotony maculopathy, suprachoroidal hemorrhage, retinal detachment, stromal necrosis, and infectious keratitis. Secondary outcomes included intraocular pressure control, worsening of visual acuity, cystoid macular edema, retroprosthetic membrane formation, persistent epithelial defect formation, GDD exposure, and KPro removal. RESULTS: One hundred thirty-seven KPro procedures were performed in 129 patients: 91 (66.4%) KPro alone and 46 (33.6%) KPro plus GDD. There were no statistically significant differences between the 2 groups in terms of the incidence of vision-threatening postoperative complications. None of the 46 GDDs placed at the same time as the KPro became exposed during an average follow-up of 44 months. CONCLUSIONS: Compared with KPro alone, GDD placement combined with KPro was not associated with increased postoperative complications.

Integrative functional genomics of hepatitis C virus infection identifies host dependencies in complete viral replication cycle.

Recent functional genomics studies including genome-wide small interfering RNA (siRNA) screens demonstrated that hepatitis C virus (HCV) exploits an extensive network of host factors for productive infection and propagation. How these co-opted host functions interact with various steps of HCV replication cycle and exert pro- or antiviral effects on HCV infection remains largely undefined. Here we present an unbiased and systematic strategy to functionally interrogate HCV host dependencies uncovered from our previous infectious HCV (HCVcc) siRNA screen. Applying functional genomics approaches and various in vitro HCV model systems, including HCV pseudoparticles (HCVpp), single-cycle infectious particles (HCVsc), subgenomic replicons, and HCV cell culture systems (HCVcc), we identified and characterized novel host factors or pathways required for each individual step of the HCV replication cycle. Particularly, we uncovered multiple HCV entry factors, including E-cadherin, choline kinase α, NADPH oxidase CYBA, Rho GTPase RAC1 and SMAD family member 6. We also demonstrated that guanine nucleotide binding protein GNB2L1, E2 ubiquitin-conjugating enzyme UBE2J1, and 39 other host factors are required for HCV RNA replication, while the deubiquitinating enzyme USP11 and multiple other cellular genes are specifically involved in HCV IRES-mediated translation. Families of antiviral factors that target HCV replication or translation were also identified. In addition, various virologic assays validated that 66 host factors are involved in HCV assembly or secretion. These genes included insulin-degrading enzyme (IDE), a proviral factor, and N-Myc down regulated Gene 1 (NDRG1), an antiviral factor. Bioinformatics meta-analyses of our results integrated with literature mining of previously published HCV host factors allows the construction of an extensive roadmap of cellular networks and pathways involved in the complete HCV replication cycle. This comprehensive study of HCV host dependencies yields novel insights into viral infection, pathogenesis and potential therapeutic targets.

Treatment Course of Patients with Exudative Age-Related Macular Degeneration Using Ocular Hypotensives.

PURPOSE: To characterize the visual outcomes and the treatment course of patients with exudative age-related macular degeneration (AMD) based on ocular hypotensive use. DESIGN: A matched retrospective cohort study of patients enrolled in Kaiser Permanente Southern California health plan was conducted. Patients taking ocular hypotensives were identified using pharmacy dispensing data and were matched to controls to compare visual acuity, number of anti-VEGF injections, and conversation to secondary anti-VEGF agents in the first year of treatment. Subgroup analysis was performed based on the number of ocular hypotensive agents (0, 1, 2 or 3+ agents) and drug class (aqueous suppressants and prostaglandin analogs). RESULTS: A total of 234 patients patients were examined. Baseline and final visual acuity did not significantly differ between drop users and controls, including on subgroup analysis. The average number of anti-VEGF injections did not differ between drop users and controls (6.1 vs 6.2, p=0.97), nor did the percentage of patients who were switched to a second-line anti-VEGF agent (23.9% vs 17.9%, p=0.26). Subgroup analysis did not reveal significant differences in the number of anti-VEGF injections and the percentage of patients switched to secondary agents, with patients receiving 6 ±1 injections across regardless of the number or class of ocular hypotensive agents used. CONCLUSION: Patients with concurrent glaucoma and exudative AMD have similar visual outcomes and treatment courses compared to those not taking ocular hypotensives. Although aqueous suppressants have been suggested to prolong anti-VEGF residence time, patients using these agents did not demonstrate visual benefit or a reduced injection burden in this series.

Hepatitis C Virus Infection Induces Hepatic Expression of NF-κB-Inducing Kinase and Lipogenesis by Downregulating miR-122.

Hepatitis C virus (HCV) harnesses host dependencies to infect human hepatocytes. We previously identified a pivotal role of IκB kinase α (IKK-α) in regulating cellular lipogenesis and HCV assembly. In this study, we defined and characterized NF-κB-inducing kinase (NIK) as an IKK-α upstream serine/threonine kinase in IKK-α-mediated proviral effects and the mechanism whereby HCV exploits this innate pathway to its advantage. We manipulated NIK expression in Huh7.5.1 cells through loss- and gain-of-function approaches and examined the effects on IKK-α activation, cellular lipid metabolism, and viral assembly. We demonstrated that NIK interacts with IKK-α to form a kinase complex in association with the stress granules, in which IKK-α is phosphorylated upon HCV infection. Depletion of NIK significantly diminished cytosolic lipid droplet content and impaired HCV particle production. NIK overexpression enhanced HCV assembly, and this process was abrogated in cells deprived of IKK-α, suggesting that NIK acts upstream of IKK-α. NIK abundance was increased in HCV-infected hepatocytes, liver tissues from Alb-uPA/Scid mice engrafted with human hepatocytes, and chronic hepatitis C patients. NIK mRNA contains an miR-122 seed sequence binding site in the 3' untranslated region (UTR). miR-122 mimic and hairpin inhibitor directly affected NIK levels. In our hepatic models, miR-122 levels were significantly reduced by HCV infection. We demonstrated that HNF4A, a known transcriptional regulator of pri-miR-122, was downregulated by HCV infection. NIK represents a bona fide target of miR-122 whose transcription is downregulated by HCV through reduced HNF4A expression. This effect, together with the sequestering of miR-122 by HCV replication, results in "derepression" of NIK expression to deregulate lipid metabolism.IMPORTANCE Chronic hepatitis C virus (HCV) infection is a major global public health problem. Infection often leads to severe liver injury that may progress to cirrhosis, hepatocellular carcinoma, and death. HCV coopts cellular machineries for propagation and triggers pathological processes in the liver. We previously identified a pivotal role of IKK-α in regulating cellular lipid metabolism and HCV assembly. In this study, we characterized NIK as acting upstream of IKK-α and characterized how HCV exploits this innate pathway to its advantage. Through extensive mechanistic studies, we demonstrated that NIK is a direct target of miR-122, which is regulated at the transcription level by HNF4A, a hepatocyte-specific transcription factor. We show in HCV infection that NIK expression is increased while both HNF4A and miR-122 levels are decreased. NIK represents an important host dependency that links HCV assembly, hepatic lipogenesis, and miRNA biology.

Demographic and socioeconomic barriers and treatment seeking behaviors of patients with infectious keratitis requiring therapeutic penetrating keratoplasty.

Purpose: To understand demographic and socioeconomic barriers and treatment-seeking behaviors of patients with infectious keratitis requiring therapeutic penetrating keratoplasty (TPK) in a developing country. Methods: This prospective non-comparative questionnaire- based study included all patients presenting to Aravind Eye Hospital, Madurai with infectious keratitis that eventuated to TPK between November 2015 and October 2016. A structured questionnaire was administered on post-operative day 3 to collect data on the demographic details, predisposing factors, prior treatment received, and treatment expenditures. Results: In total, 227 patients underwent TPK between November 2015 and October 2016 for infectious keratitis. The majority of patients were males (n = 132, 58.1%), illiterate (n = 129, 56.8%), and had a family monthly income of less than INR 6000 (n = 142, 62.5%). Most of the patients (n = 163, 71.8%) had prior treatment with an ophthalmologist before presenting to our hospital. The mean distance travelled to reach our centre was 269.2 ± 298.5 km. The mean duration of disease before the presentation was 20.3 ± 21.1 days. Corneal smear was positive for fungus in 163 (88.1%) and Aspergillus was the most commonly isolated fungi in 55 (41.3%) cultures. The mean total cost of treatment was INR 8752.87 ± 7615.39 per patient. There was a positive correlation between the duration of the disease (rho 0.19, P = 0.0034) and the costs of treatment (rho 0.2, P = 0.0024) with the distance travelled by the patient. Conclusion: Patients who travelled a farther distance had a delayed onset of presentation and spent significantly more than their respective counterparts.

Two-Year Incidence of Retinal Intervention in Patients With Minimal or No Diabetic Retinopathy on Telemedicine Screening.

Importance: Most patients with diabetes have little or no retinopathy on initial examination. Tracking the long-term outcomes of these patients may increase our understanding of how to best provide follow-up treatment. Objective: To assess how many patients with minimal or no retinopathy require retinal intervention within 2 years of retinal evaluation. Design, Setting, and Participants: This retrospective cohort study assessed patients who underwent screening for diabetic retinopathy within a telemedicine program at Kaiser Permanente Southern California and had minimal or no retinopathy on fundus photographs. Exposure: Retinal interventions performed within 2 years of photographs. Main Outcomes and Measures: Patients with minimal or no retinopathy on initial screening photographs taken in 2012 had their medical records searched for Current Procedural Terminology codes for intravitreal injections, retinal lasers, or pars plana vitrectomy. The medical records of patients identified as having received these interventions within 2 years of retinal evaluation were then manually reviewed for further characterization. Results: Diabetic retinopathy screening photographs were taken for 116 134 patients (mean [SD] age, 58 [12.8] years; 54 582 [47.0%] female; 46 453 [40.0%] Latino). Of these patients, 79 445, including 69 634 patients without retinopathy and 9811 patients with minimal retinopathy, had 2 years of follow-up. Eleven patients without baseline retinopathy required treatment of diabetic retinopathy in the following 2 years (1 of 12 660 or 0.000079 patients per year), and 11 patients with minimal retinopathy required intervention during the same period (1 of 1784 or 0.000561 patients per year). In addition, retinal interventions were performed for conditions not directly related to diabetic eye disease in 44 patients without baseline retinopathy (1 of 3165 or 0.000316 patients per year) and 5 patients with minimal retinopathy at baseline (1 of 3924 or 0.000255 patients per year). Conclusions and Relevance: These findings suggest that it is rare for patients with minimal or no baseline retinopathy to require retinal interventions in the 2 years after retinal evaluation. It appears that extending the recommended follow-up interval for low-risk patients may be reasonable as long as this does not lead to worse follow-up in later years, because most are unlikely to have vision-threatening disease that necessitates treatment.

Coding patterns used by ophthalmologists for hydroxychloroquine retinal toxicity.

PURPOSE: The aim of this study was to characterize International Classification of Diseases (ICD-9) coding patterns used by ophthalmologists in clinical practice for hydroxychloroquine (HCQ) retinal toxicity. DESIGN: This is a retrospective cohort study. SUBJECTS: Patients enrolled in the Kaiser Permanente Southern California health plan who were dispensed HCQ between 2001 and 2014 were included in this study. METHODS: Patients' medical records were electronically searched for the following ICD-9 codes that can be used to characterize retinopathy or maculopathy: toxic maculopathy, non-exudative age-related macular degeneration (AMD), drusen (degenerative), and/or (other) background retinopathy. The charts of patients with these codes were then manually reviewed to determine which of these patients had been diagnosed by their ophthalmologists with HCQ retinopathy. MAIN OUTCOME MEASURES: ICD-9 codes used to indicate HCQ toxicity. RESULTS: A total of 23,362 patients were dispensed HCQ between 2001 and 2014. Of whom, 678 (2.9%) patients received at least one of the aforementioned ICD-9 codes with 53 having confirmed HCQ toxicity on chart review. Forty-three patients who were taking HCQ received a diagnosis code for toxic maculopathy, and of whom, 35 (81.4%) had HCQ toxicity. Of the patients with confirmed HCQ toxicity, 32.1% received a code other than toxic maculopathy to connote the presence of disease. CONCLUSION: Although toxic maculopathy is the most commonly used ICD-9 code to identify patients with HCQ toxicity, a significant number of patients with toxicity received other codes in their medical records. Additionally, almost one-fifth of the patients who were coded as having toxic maculopathy were ultimately not diagnosed with HCQ toxicity. This study underscores the often imprecise nature of ICD coding, especially in conditions without a specific associated code. The limitations of using coding information should also be considered when conducting research that utilizes electronic databases. Future investigations should determine how to improve database searches and methods to create more uniform coding standards among ophthalmologists, especially for rare conditions such as HCQ toxicity.

Variable validity of computer extracted problem lists for complications of diabetes mellitus within the VA Greater Los Angeles Health System.

PURPOSE: Electronic health data in the form of International Classification of Disease, Ninth Revision (ICD-9) codes is routinely used for clinical research, yet the accuracy of specific diagnoses is largely unknown. The purpose of this study is to assess the validity of computer extracted problem lists for diabetic retinopathy (DR) and other complications of diabetes mellitus (DM) within the VA Greater Los Angeles Health Administration (VHAGLA). METHODS: The study population consisted of patients at the VHAGLA with an ICD-9 diagnosis of DM between Jan 1st 1999 and March 22nd 2016 with visits to the eye clinic. Fifty patients either with or without an ICD-9 diagnosis of DR were randomly selected. The accuracy of ICD-9 codes for DR, as well as related co-morbidities such as hypertension, hyperlipidemia, coronary artery disease (CAD), and cerebrovascular accident (CVA), were assessed through chart review. RESULTS: A total of 3193 patients met our inclusion criteria. Of the 50 patients with an ICD-9 diagnosis of DR, the positive predictive value (PPV) was 0.7. For 50 patients without a ICD-9 diagnosis of DR, the negative predictive value (NPV) was 0.9. Of the other co-morbid medical conditions, NPV ranged from a low of 63% for obesity to a high of 98% for CVA and CAD. CONCLUSION: Validity of ICD-9 diagnoses of diabetic complications in this VA population varied considerably, with DR demonstrating moderate agreement, obesity being more under-documented, and CVA and CAD being more consistently documented. These discrepancies should be considered when using billing codes for research purposes.

Cellular microRNA networks regulate host dependency of hepatitis C virus infection.

Cellular microRNAs (miRNAs) have been shown to regulate hepatitis C virus (HCV) replication, yet a systematic interrogation of the repertoire of miRNAs impacting HCV life cycle is lacking. Here we apply integrative functional genomics strategies to elucidate global HCV-miRNA interactions. Through genome-wide miRNA mimic and hairpin inhibitor phenotypic screens, and miRNA-mRNA transcriptomics analyses, we identify three proviral and nine antiviral miRNAs that interact with HCV. These miRNAs are functionally linked to particular steps of HCV life cycle and related viral host dependencies. Further mechanistic studies demonstrate that miR-25, let-7, and miR-130 families repress essential HCV co-factors, thus restricting viral infection at multiple stages. HCV subverts the antiviral actions of these miRNAs by dampening their expression in cell culture models and HCV-infected human livers. This comprehensive HCV-miRNA interaction map provides fundamental insights into HCV-mediated pathogenesis and unveils molecular pathways linking RNA biology to viral infections.

Investigating the Molecular Basis of PPCD3: Characterization of ZEB1 Regulation of COL4A3 Expression.

PURPOSE: To investigate the role of the zinc finger e-box binding homeobox 1 (ZEB1) transcription factor in posterior polymorphous corneal dystrophy 3 by demonstrating its ability to regulate type IV collagen gene transcription via binding to putative E2 box motifs. METHODS: Putative E2 box motifs were identified by in silico analysis within the promoter region of collagen, type IV, alpha3 (COL4A3) and collagen, type IV, alpha4 (COL4A4). To test the ability of ZEB1 to bind to each identified E2 box, electrophoretic mobility shift assays were performed by incubating ZEB1-enriched nuclear extracts with DIG-labeled probes containing one of each of the identified E2 box motifs. Dual-luciferase reporter assays were performed to test the effects of ZEB1 on the luciferase activity of COL4A3 and cadherin 1 (CDH1) promoter constructs, and to determine the effect of a ZEB1 truncating mutation on CDH1 promoter activity. RESULTS: ZEB1 exhibited binding to six of the nine COL4A3 E2 box probes, whereas no binding was observed for either of the two COL4A4 E2 box probes. ZEB1 overexpression resulted in reduced activity of the COL4A3 promoter construct containing all identified E2 box motifs, whereas a truncating ZEB1 mutation led to the loss of ZEB1-dependent repression of the CDH1 promoter. CONCLUSIONS: COL4A3 gene expression is negatively regulated by ZEB1 binding to E2 box motifs in the COL4A3 promoter region. Therefore, the altered expression of type IV collagens, particularly COL4A3, in the corneal endothelium in individuals with PPCD3 is likely due to reduced transcriptional repression in the setting of a single functional ZEB1 allele.

Identification of the First De Novo UBIAD1 Gene Mutation Associated with Schnyder Corneal Dystrophy.

Purpose. To report the identification of the first de novo UBIAD1 missense mutation in an individual with Schnyder corneal dystrophy (SCD). Methods. A slit lamp examination was performed on a 47-year-old woman without a family history of corneal disorders. The proband's parents, two sisters, and son were also examined and genomic DNA from all six individuals was collected. The exons and exon-intron boundaries of UBIAD1 were screened using Sanger sequencing. Identified mutations were screened for in 200 control chromosomes. In silico analysis predicted the impact of identified mutations on protein function and structure. Results. Slit lamp examination of the proband revealed findings consistent with SCD. Corneas of the family members appeared unaffected. Screening of UBIAD1 in the proband identified a novel heterozygous c.308C>T mutation, predicted to encode the missense amino acid substitution p.(Thr103Ile). This mutation was not identified in any of the family members or in 200 control chromosomes and was predicted to be damaging to normal protein function and structure. Conclusions. We present a novel heterozygous de novo missense mutation in UBIAD1, p.(Thr103Ile), identified in a patient with classic clinical features of SCD. This highlights the value of genetic testing in clinical diagnostic settings, even in the absence of a positive family history.