MRI surveillance after translabyrinthine vestibular schwannoma resection and cochlear implantation: is it feasible?

PURPOSE: Cochlear implantation in patients with vestibular schwannomas is of increasing importance and interest. Two remaining challenges are the assessment of conduction of the cochlear nerve and the possibility of postoperative surveillance with magnetic resonance imaging. The aim of the current study was to assess follow-up imaging and determine the visibility of the internal auditory canal after vestibular schwannoma resection and cochlear implantation as well as in patients with persistent vestibular schwannomas and cochlear implants in place. Visibility of the internal auditory canal, cerebellopontine angle, and labyrinth were evaluated and graded. METHODS: For this retrospective study, 15 MR examinations of 13 patients after translabyrinthine vestibular schwannoma resection and ipsilateral cochlear implantation were included. All patients had been implanted with an MED-EL cochlear implant. Magnetic resonance imaging was carried out on a 1.5T device. All patients were prepped according to the manufacturer's recommendations. RESULTS: All 15 examinations were carried out without any adverse event during imaging, such as pain, magnet dislocation, or malfunction. The internal auditory canal and the cerebellopontine angle were sufficiently visible in all cases to allow for vestibular schwannoma follow-up. CONCLUSION: Magnetic resonance imaging surveillance of the internal auditory canal following vestibular schwannoma resection and cochlear implantation is feasible and safe with modern implants with a 1.5T magnetic resonance imaging device using metal artifact reduction sequences. Necessary follow-up imaging should not be a contraindication for cochlear implantation in patients with vestibular schwannomas.

Performance of a new natural oral contrast agent (LumiVision®) in dynamic MR swallowing.

OBJECTIVES: To evaluate image quality by first use of LumiVision® in dynamic MR swallowing, a contrast medium consisting of biological substances versus a gadolinium-buttermilk mixture in patients who underwent Nissen fundoplication due to gastroesophageal reflux disease (GERD). METHODS: The protocol of this retrospective study was approved by the local Institutional Review Board. A hundred twenty-nine patients (146 examinations) underwent a dynamic MR swallowing study (at 1.5 T or 3.0 T) and received an oral contrast agent. Two readers evaluated the distention of the esophagus, contrast, and traceability of the bolus in a 3-point scale. A steady-state coherent sequence (B-FFE, TrueFISP) was used. The patients were divided into 3 different groups: 53 patients received gadolinium chelate (Dotarem®)-buttermilk mixture (GBM) in a dilution of 1:40 as an oral contrast agent; 44 patients received LumiVision® water mixture (LWM) in a dilution of 1:1 and 49 patients received LumiVision® (L) undiluted. RESULTS: GBM showed significantly better results in overall evaluation for both readers in contrast to LWM (p = .003, p = .002). L also reached significantly better results in overall evaluation than LWM in both readers (p = .004, p = .042). There was no significant difference in the overall evaluation between L and GBM (p = .914, p = .376).According to Landis and Koch, interobserver agreement was "substantial" (Cohen's kappa = 0.738) between both readers. CONCLUSION: LumiVision® undiluted showed equal image quality compared to gadolinium-buttermilk mixture. The constellation of LumiVision® water mixture led to a clearly negative result in relation to the image quality compared to LumiVision® undiluted. Therefore, oral ingestion of LumiVision® undiluted is recommended for MR swallowing examinations. KEY POINTS: • LumiVision® undiluted shows significantly better image quality in comparison to LumiVision® diluted in oral application in swallowing MRI. • LumiVision® undiluted shows equal image quality in comparison to gadolinium-buttermilk mixture in oral application. • Oral ingestion of LumiVision® undiluted can replace gadolinium-buttermilk mixture in oral MR examinations.

Swallowing MRI-a reliable method for the evaluation of the postoperative gastroesophageal situs after Nissen fundoplication.

PURPOSE: To evaluate the diagnostic performance of swallowing MRI of the gastroesophageal junction (GEJ) in the postoperative care of patients after laparoscopic antireflux surgery (LARS) MATERIAL AND METHODS: In this institutional review board-approved prospective study, 79 symptomatic patients (mean age, 52.3 years; range, 26-80 years) were evaluated after laparoscopic Nissen fundoplication. MRI findings were correlated with revision surgery, endoscopy, and high-resolution manometry (HRM) as standard of reference. MRI was performed on a 3.0-T unit using T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences for anatomical assessment of the GEJ followed by dynamic MR swallowing (fast low-angle shot sequences). Four independent readers (two radiologists, two surgeons) rated 83 MR scans according to defined criteria, such as wrap disruption, slipping, recurrent hiatal hernia, and esophageal motility disorder. RESULTS: Wrap disruption was correctly diagnosed concordantly with the standard of reference in 87.8%, slipping in 81.5%, and recurrent hiatal hernia in 84.9% of the cases. For esophageal motility disorder, MRI interpretation was consistent with manometry in 66.2% of the subjects. Interobserver analysis showed substantial agreement for recurrent hiatal hernia (k = 0.703), moderate agreement for wrap disruption (k = 0.585), and fair agreement for motility disorder and slipping (k = 0.234 and k = 0.200, respectively). CONCLUSION: MR swallowing readily depicts the major failure mechanisms of LARS and has good reliability even in non-experienced readers. KEY POINTS: • MR swallowing accurately readily depicts the major failure mechanisms of laparoscopic antireflux surgery and has good reliability even in non-experienced readers. • It should be included in the preoperative workup for revision surgery after fundoplication. • It will be of great benefit to surgeons in considering and planning a reoperation.

Effects of corneal nerve density on the response to treatment in dry eye disease.

PURPOSE: To evaluate whether levels of corneal subbasal nerve fiber length (SNFL) in dry eye disease (DED) could prognosticate the level of improvement in signs and symptoms after treatment. DESIGN: Phase IV, double-masked, randomized clinical trial. PARTICIPANTS: Sixty patients with meibomian gland dysfunction-associated DED and 27 age-matched controls. METHODS: Patients with DED were randomized to receive topical artificial tears, loteprednol etabonate 0.5%, or loteprednol etabonate 0.5%/tobramycin 0.3% twice daily for 4 weeks. At baseline, in vivo confocal microscopy of central cornea was performed in both eyes. Patients with DED were divided into 2 subgroups: those with low baseline SNFL and those with near-normal baseline SNFL for this purpose (the cutoff point: the mean SNFL in controls minus 2 standard deviations). Clinical signs and symptoms at baseline and after 4 weeks of treatment were compared between the subgroups with low and near-normal SNFL for all therapeutic groups. MAIN OUTCOME MEASURES: Symptom questionnaires, corneal fluorescein staining (CFS), conjunctival staining with lissamine green, tear break-up time, Schirmer's test, and SNFL. RESULTS: In patients with DED, baseline SNFL (17.06±5.78 mm/mm(2)) was significantly lower than in controls (23.68±3.42 mm/mm(2), P = 0.001). In the artificial tear and loteprednol groups, although no significant improvement in any sign or symptom was noted in patients with low baseline SNFL (<16.84 mm/mm(2)), subjects with near-normal baseline SNFL (≥16.84 mm/mm(2)) showed significant improvement in both symptoms and CFS score (all P < 0.05). In the loteprednol/tobramycin group, no significant change was evident for any sign or symptom in either subgroup of low or near-normal baseline SNFL. CONCLUSIONS: Significant improvements in CFS and patient symptomatology after DED treatment were evident only in the subgroup with near-normal corneal SNFL. Consideration of SNFL may assist in explaining the variability of patients' response to DED therapy.

Intrathoracic pouch migration in one-anastomosis gastric bypass with and without hiatoplasty: A 3-dimensional-computed tomography volumetry study.

BACKGROUND: Currently, 4.8% of bariatric operations worldwide are one-anastomosis gastric bypass (OAGB) procedures. If a hiatal hernia is detected in a preoperative gastroscopy, OAGB can be combined with hiatoplasty. Intrathoracic pouch migration (ITM) is common after bypass procedures because the fundus, a natural abutment, is separated from the pouch. OBJECTIVE: The aim of this study was to find out whether OAGB or OAGB combined with hiatoplasty carries a higher risk of ITM and, therefore, also gastroesophageal reflux disease (GERD). SETTING: University hospital. METHODS: Fifty patients (group 1: 25× primary OAGB; group 2: 25× primary OAGB with hiatoplasty) were included in this study. History of weight, GERD, and quality of life were recorded in patient interviews and pouch volume and ITM were evaluated using 3-dimensional-computed tomography volumetry. RESULTS: There were no differences in terms of patient characteristics, history of weight, pouch volume, or quality of life between both groups. ITM was found in group 1 in 60% (n = 15) and group 2 in 76% (n = 19) of all patients (P = .152). The ITM mean length was significantly lower in group 1 with .9 ± 1.1 cm than in group 2 with 1.8 ± 1.2 cm (P = .007). Regarding GERD, there was no difference between both groups; nevertheless, significantly more patients with ITM (38.2%; n = 13) had GERD compared with patients without ITM (6.3%; n = 1). CONCLUSION: In primary OAGB, an additional hiatoplasty was not associated with higher rates of ITM or GERD; nevertheless, the length of ITM was higher after hiatoplasty. If ITM occurs, patients have a risk of developing GERD.

Neuroradiological differentiation of white matter lesions in patients with multiple sclerosis and Fabry disease.

OBJECTIVE: White matter lesions (WML) in multiple sclerosis (MS) differ from vascular WML caused by Fabry disease (FD). However, in atypical cases the discrimination can be difficult and may vary between individual raters. The aim of this study was to evaluate interrater reliability of WML differentiation between MS and FD patients. MATERIALS AND METHODS: Brain MRI scans of 21 patients with genetically confirmed FD were compared to 21 matched patients with MS. Pseudonymized axial FLAIR sequences were assessed by 6 blinded raters and attributed to either the MS or the FD group to investigate interrater reliability. Additionally, localization of WML was compared between the two groups. RESULTS: The median age of patients was 46 years (IQR 35-58). Interrater reliability was moderate with a Fleiss' Kappa of 0.45 (95%CI 0.3-0.59). Overall, 85% of all ratings in the MS group and 75% in the FD group were correct. However, only 38% of patients with MS and 33% of patients with FD were correctly identified by all 6 raters. WML involving the corpus callosum (p < 0.001) as well as juxtacortical (p < 0.001) and infratentorial lesions (p = 0.03) were more frequently observed in MS patients. CONCLUSION: Interrater reliability regarding visual differentiation of WML in MS from vascular WML in FD on standard axial FLAIR images alone is only moderate, despite the distinctive features of lesions in each group.

Rectal preparation significantly improves prostate imaging quality: Assessment of the PI-QUAL score with visual grading characteristics.

PURPOSE: To investigate the effects of a rectal preparation regimen, that consisted of a rectal cleansing enema and an endorectal gel filling protocol, on prostate imaging quality (PI-QUAL). METHODS: Multiparametric MRI (mpMRI) was performed in 150 consecutive patients divided into two groups of 75 patients. One group received a rectal preparation with a cleansing enema and endorectal gel filling (median age 65.3 years, median PSA level 6 ng/ml). The other patient group did not receive such a preparation (median age 64 years, median PSA level 6 ng/ml). Two uroradiologists independently rated general image quality and lesion visibility on diffusion-weighted imaging (DWI), T2-weighted (T2w), and dynamic contrast-enhanced (DCE) images using a five-point ordinal scale. In addition, two uroradiologists assigned PI-QUAL scores, using the dedicated scoring sheet. Data sets were compared using visual grading characteristics (VGC) and receiver operating characteristics (ROC)/ area under the curve (AUC) analysis. RESULTS: VGC revealed significantly better general image quality for DWI (AUC R1 0.708 (0.628-0.779 CI, p < 0.001; AUC R2 0.687 (0.606-0.760 CI, p < 0.001) and lesion visibility for both readers (AUC R1 0.729 (0.607-0.831 CI, p < 0.001); AUC R2 0.714 (0.590-0.818CI, p < 0.001) in the preparation group. For T2w imaging, rectal preparation resulted in significantly better lesion visibility for both readers (R1 0.663 (0.537-0.774 CI, p = 0.014; R2 0.663 (0.537-0.774 CI, p = 0.014)). Averaged PI-QUAL scores were significantly improved with rectal preparation (AUC R3/R4 0.667, CI 0.581-0.754, p < 0.001). CONCLUSION: Rectal preparation significantly improved prostate imaging quality (PI-QUAL) and lesion visibility. Hence, a rectal preparation regimen consisting of a rectal cleansing enema and an endorectal gel filling could be considered.

Omalizumab-Induced Aspirin Tolerance in Nonsteroidal Anti-Inflammatory Drug-Exacerbated Respiratory Disease Patients Is Independent of Atopic Sensitization.

BACKGROUND: Nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) comprises the triad of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and intolerance to inhibitors of the cyclooxygenase-1 enzyme. The impact of omalizumab on prevention of aspirin-induced hypersensitivity in N-ERD patients with and without atopic sensitization has not been thoroughly addressed. OBJECTIVE: To investigate the effect of omalizumab treatment on aspirin tolerance in atopic and nonatopic N-ERD patients. METHODS: This single-center, prospective trial evaluated overall omalizumab-induced aspirin tolerability in N-ERD patients by performing aspirin challenge testing before and after 6 months of anti-immunoglobulin E (IgE) therapy. The impact of omalizumab on CRSwNP asthma as well as serum and tissue biomarkers in patients with and without comorbid atopic sensitizations was further analyzed. RESULTS: Out of 33 patients included in the study, 56% developed complete aspirin tolerance and 18% tolerated higher dosages after 24 weeks. Polyp size and disease-specific symptoms (nasal polyp score [NPS] -1.9 ± 0.3, P < .001; Sino-Nasal Outcome Test [SNOT]-20 -16.7 ± 3.7, P < .001; Asthma Control Test [ACT] 3.2 ± 0.7, P < .001) improved in all patients irrespective of atopic sensitization. Effectiveness of omalizumab was accompanied by an increase in mean total serum IgE (307.8 ± 42 kU/L; P < .001) and a decrease in eosinophilic cationic protein (-10.6 ± 6.7 µg/L) and in relative eosinophilia (-2.5 ± 0.7%; P < .01). Whereas there was a significant reduction of tissue IgE (P < .05) in all patients after 4 weeks, the number of local eosinophils decreased only in atopic individuals (P < .05). CONCLUSIONS: Omalizumab induced complete aspirin tolerance in the majority of patients (56%) independent of atopic sensitization and demonstrated clinical efficacy in the treatment of CRSwNP and asthma. Inhibition of IgE can therefore be a promising treatment option in preventing NSAID hypersensitivity reactions in N-ERD patients.

Severe gastroparesis after orthotopic heart transplantation.

We present a case of severe gastroparesis in a recipient of orthotopic heart transplantation. Although a rare condition after heart transplantation, it is a potential cause of significant morbidity, including vomiting, aspiration and pneumonia. Moreover, impaired gastric emptying alters the pharmacokinetics of immunosuppressive medication with increased risk of severe side effects. Herein, we describe a diagnostic and therapeutic strategy that was successfully applied in a patient with gastroparesis.

Titanium and Platinum-Fluoroplastic Stapes Prostheses Visualization on Cone Beam Computed Tomography and High-Resolution Computed Tomography.

Objective: The aim of this study was to evaluate whether stapes prostheses can be visualized with less metal artifacts and therefore more accurately on cone beam computed tomography in comparison to computed tomography imaging. Recent studies have shown that cone beam computed tomography has advantages when imaging metal artifacts. Patients with hearing loss or vertigo, who have undergone stapedotomy, often present a challenge for otologic surgeons. Imaging studies can deliver crucial additional information. Methods: A retrospective analysis of imaging studies and clinical data in a tertiary care center were carried out. Forty-one patients with forty-five implanted ears were evaluated in the study. All included patients had been implanted with a platinum-fluoroplastic (n = 19) or titanium (n = 26) piston and subsequently had undergone imaging months or years after surgery for various reasons. Patients underwent computed tomography or cone beam computed tomography of the temporal bone depending on availability. Piston visualization, prosthesis length, vestibular intrusion and audiologic results were compared between the groups. Piston position on imaging studies were compared to intraoperative findings. Results: Functional length measurements of all prostheses were carried out with a mean error of -0.17 mm (±0.20). Platinum-fluoroplastic protheses were significantly underestimated in length compared to titanium prostheses. To analyze the material-dependent difference in the measurement errors of the imaging techniques the interaction was tested in an ANOVA model and showed no statistically significant result (p = 0.24). The blinded neuroradiologist viewed two implants, both platinum-fluoroplastic pistons, as located outside of the vestibule due to an underestimation of the prothesis length and the missing radiodensity of the lower end of the prosthesis. Conclusion: Surgeons and radiologists should be aware of the different types and radiologic features of stapes prostheses and the missing radiodensity of some protheses parts. Cone beam computed tomography is an imaging alternative with a potential advantage of reduced radiation in patients after stapes surgery suffering from vertigo or hearing loss to evaluate piston position.

Pouch volume and pouch migration after Roux-en-Y gastric bypass: a comparison of gastroscopy and 3 D-CT volumetry: is there a "migration crisis"?

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the second most frequently performed bariatric procedure worldwide. While pouch migration is a common phenomenon after sleeve gastrectomy, it has hardly been documented after RYGB so far. OBJECTIVES: The aim of this study was to correlate the diagnostic performance of gastroscopy of the gastroesophageal junction with 3-dimensional computed tomography (CT) during postoperative care of patients revised due to weight regain after RYGB, with particular attention to intrathoracic pouch migration (ITM) and pouch volume. SETTING: University Hospital Setting, Austria. METHODS: Thirty RYGB patients that were revised owing to weight regain (median age 37.5 yr) before December 2017 were included in this prospective study. CT findings were correlated with gastroscopy regarding pouch size and ITM. Pouch distention was achieved with both oral contrast and effervescent granules. All patients had CT and gastroscopy on the same day. In addition, patients were evaluated for reflux disease based on clinical history. RESULTS: ITM was found in 20 of 30 (66.7%) patients in CT, whereas gastroscopy did not correctly identify any herniation. In 16 of 28 (57.1%) patients pouch measurements at gastroscopy and CT showed a difference <40%. In 2 patients, pouch distention was not sufficient for CT volumetry. The intraclass correlation coefficient proved to be .594. Symptomatic reflux was present in 10 of 30 (33.3%) patients, 5 of whom had ITM. CONCLUSION: ITM is an underreported finding after revised RYGB and missed in gastroscopy. In terms of pouch volume, 3-dimensional-CT volumetry demonstrated only moderate agreement with gastroscopy.

Swallow Magnetic Resonance Imaging Compared to 3D-Computed Tomography for Pouch Assessment and Hiatal Hernias After Roux-en-Y Gastric Bypass.

INTRODUCTION/PURPOSE: Weight regain and weight loss failure after bariatric surgery are important issues that may require a weight regain procedure. Three-dimensional-computed tomography (3D-CT) is a well-established method allowing exact measurements of pouch volume. The aims of this study were to prove the applicability of swallow MRI as a non-ionizing procedure and compare it to 3D-CT in patients after weight regain procedures following RYGB. MATERIALS AND METHODS: Twelve post-RYGB patients who had a follow-up operation for weight regain before 12/2017 were included in this prospective study. Swallow MRI and 3D-CT were performed in each patient to evaluate the size of the anastomosis, pouch volume, and intrathoracic pouch migration (ITM). RESULTS: Mean pouch volume in swallow MRI and 3D-CT were 40.4 ± 21.0 ml and 43.5 ± 30.2 ml, respectively (p = 0.83), and pouch diameter at the maximal distention was 35.3 ± 5.9 ml (MRI) and 31.0 ± 10.0 ml (CT) (p = 0.16). The rate of ITM was 75% in both examinations (p = 1.0). CONCLUSION: Swallow MRI is a valid method for the assessment of pouch volume in different phases of the swallowing process and is comparable to 3D-CT. The diagnosis of ITM using swallow MRI was equal to 3D-CT.

When an incidental MRI finding becomes a clinical issue : Posterior lumbar subcutaneous edema in degenerative, inflammatory, and infectious conditions of the lumbar spine.

BACKGROUND: On magnetic resonance imaging (MRI), posterior lumbar subcutaneous edema (PLSE) is a frequent incidental, yet unclear finding within the deep subcutaneous perifascial tissue. This study aimed to investigate PLSE in various pathological lumbar conditions. METHODS: This retrospective study included the MR images of the lumbar spine of 279 patients (age range 18-82 years) without cardiovascular, renal or hepatic diseases, 79 of whom had low-grade disc degeneration, 101 combined endplate and facet joint degeneration, 53 axial spondyloarthritis and 46 infectious spondylodiscitis. There were 232 patients with a body mass index (BMI) <30, and 47 with a BMI ≥30 (obese). For each group, the relationship between PLSE and BMI was analyzed using multiple logistic regression, and between PLSE extension and BMI using ordinal regression. RESULTS: A PLSE was found in 11/79 (13.9%) patients with disc degeneration, 37/101 (36.6%) with endplate and facet joint degeneration, 7/53 (13.2%) with spondyloarthritis, and 28/46 (60.9%) with spondylodiscitis. For each group, a statistically significant relationship was demonstrated between PLSE and BMI (P = 0.000-P = 0.031), except for spondylodiscitis (P = 0.054), as well as between PLSE extension and BMI (P = 0.000-P = 0.049). A PLSE was found in 21.1% of nonobese and 72.3% of obese patients (P = 0.000). CONCLUSION: The presence of PLSE seems to be associated with various lumbar conditions, particularly in obese patients. Its perifascial location may suggest a potential fascial origin; however, PLSE should not to be confused with posttraumatic, postsurgical or infectious edema or edema associated with internal diseases.

Surgical therapy of weight regain after Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is a well-established surgical method for morbid obesity; however, weight regain (WR) after initially good results may be considered an issue, the treatment of which has found no consensus yet. OBJECTIVES: The aim of this study was to compare the different surgical methods treating WR after RYGB that are used at the Vienna Medical University in a larger number of patients, concerning further weight loss, complications, and reoperations. SETTING: University hospital, Austria. METHODS: This study includes all patients with RYGB who were reoperated due to WR at the Vienna Medical University by December 2016 (n = 84). The follow-up rate was 93%. The following 4 approaches to treating WR after RYGB were taken: (1) pouch resizing, (2) pouch banding, (3) pouch resizing plus pouch banding, and (4) common limb shortening (i.e., distalization). RESULTS: The mean maximum excess weight loss referring to the WR procedure in the 4 groups was as follows: group 1: 69.0% ± 35.2%, group 2: 62.8% ± 39.5%, group 3: 83.1% ± 30.9%, and group 4: 81.5% ± 41.6%. Reoperations occurred in the following different groups: group 1 had 2 balloon dilations (20%), groups 2 (n = 13) and 3 (n = 29) had 5 (38% and 17%) band removals each, and group 4 had 9 reversal procedures due to malnutrition (30%). CONCLUSIONS: There are nonsignificant differences in terms of additional weight loss between the different methods. However, differences lay in the areas of adverse symptoms and further reoperations. While there was no risk of malnutrition with pouch resizing, there was with distalization. Pouch banding (with or without resizing) poses a higher risk of dysphagia.

In Vivo Confocal Microscopy in Dry Eye Disease Associated With Chronic Graft-Versus-Host Disease.

PURPOSE: To compare densities of corneal epithelial dendritic cells (DCs), corneal subbasal nerves, and conjunctival epithelial immune cells (EICs) between patients with dry eye disease (DED) with and without graft-versus-host disease (GVHD) using in vivo confocal microscopy (IVCM). METHODS: This study included 54 patients who had moderate to severe DED either associated with (n = 33) or without (n = 21) chronic GVHD. In addition to evaluating clinical parameters of DED, images obtained by laser-scanning IVCM of the central cornea and superior tarsal conjunctiva were analyzed to measure densities of corneal epithelial DCs, corneal subbasal nerves, and conjunctival EICs. RESULTS: Although there were no significant differences between GVHD and non-GVHD groups in symptom scores, the GVHD group had significantly worse corneal fluorescein staining, tear break-up time, and Schirmer's scores than the non-GVHD group. Corneal epithelial DC density, corneal subbasal nerve density, and conjunctival EIC density were 148 ± 135 cells/mm2, 16.3 ± 6.1 mm/mm2, and 670 ± 267 cells/mm2, respectively, in the GVHD group; and 122 ± 99 cells/mm2, 18.3 ± 5.1 mm/mm2, and 572 ± 271 cells/mm2, respectively, in the non-GVHD group. After adjusting for clinical parameters, including the DED severity, none of the IVCM parameters was significantly different between the GVHD versus non-GVHD groups (P = 0.82, P = 0.21, and P = 0.60, respectively). CONCLUSIONS: In GVHD-associated DED, cellular changes in the cornea and conjunctiva observed by IVCM were similar to those seen in patients who have non-GVHD dry eye with the same level of disease severity. Therefore, corneal and conjunctival IVCM findings in GVHD-associated DED are possibly reflective of the local disease (DED) severity rather than the underlying systemic disease process.

Imaging of posterior tibial tendon dysfunction--Comparison of high-resolution ultrasound and 3T MRI.

PURPOSE: Posterior tibial tendon dysfunction is the most common cause of acquired asymmetric flatfoot deformity. The purpose of this study was to determine and compare the diagnostic value of MRI and high-resolution ultrasound (HR-US) in posterior tibial tendon dysfunction (PTTD), and assess their correlation with intraoperative findings. MATERIALS AND METHODS: We reviewed 23 posterior tibial tendons in 23 patients with clinical findings of PTTD (13 females, 10 males; mean age, 50 years) with 18MHz HR-US and 3T MRI. Surgical intervention was performed in nine patients. RESULTS: HR-US findings included 2 complete tears, 6 partial tears, 10 tendons with tendinosis, and 5 unremarkable tendons. MRI demonstrated 2 complete tears, 7 partial tears, 10 tendons with tendinosis, and 4 unremarkable tendons. HR-US and MRI were concordant in 20/23 cases (87%). Image findings for HR-US were confirmed in six of nine patients (66.7%) by intraoperative inspection, whereas imaging findings for MRI were concordant with five of nine cases (55.6%). CONCLUSION: Our results indicate that HR-US can be considered slightly more accurate than MRI in the detection of PTTD.

Reduced Corneal Endothelial Cell Density in Patients With Dry Eye Disease.

PURPOSE: To evaluate corneal endothelial cell density (ECD) in patients with dry eye disease (DED) compared to an age-matched control group. DESIGN: Cross-sectional, controlled study. METHODS: This study included 90 eyes of 45 patients with moderate to severe DED (aged 53.7 ± 9.8 years) and 30 eyes of 15 normal controls (aged 50.7 ± 9.8 years). All subjects had a complete ophthalmic evaluation including symptom assessment using the Ocular Surface Disease Index (OSDI) and corneal fluorescein staining. In addition, laser scanning in vivo confocal microscopy was performed to measure the density of the following parameters in the central cornea: endothelial cells, subbasal nerves, and subbasal immune dendritic cells. RESULTS: Corneal ECD was significantly lower in the DED group (2595.8 ± 356.1 cells/mm(2)) than in the control group (2812.7 ± 395.2 cells/mm(2), P = .046). The DED group showed significantly lower corneal subbasal nerve density (17.1 ± 6.9 mm/mm(2)) compared to the control group (24.7 ± 4.4 mm/mm(2), P < .001). Dendritic cell density was significantly higher in the DED group than in the controls (111.7 ± 137.3 vs 32.0 ± 24.4 cells/mm(2), respectively, P = .002). There were statistically significant correlations between corneal ECD and dry eye severity parameters including the OSDI score (rs = -0.26, P = .03), and corneal fluorescein staining (rs = -0.28, P = .008). CONCLUSIONS: There is a significant reduction in corneal ECD in DED that correlates with clinical severity of the disease.

Successful treatment of Paecilomyces lilacinus keratitis with oral posaconazole.

PURPOSE: To report a case of successful medical treatment with oral posaconazole in refractory fungal keratitis caused by Paecilomyces lilacinus. METHODS: Case report. RESULTS: A 57-year-old male, soft contact lens wearer presented with irritation, pain, photophobia, and reduced vision. Slit-lamp examination showed a large corneal epithelial defect with a peripheral infiltrate. The patient did not improve on fortified topical antibiotics. After the diagnosis of P. lilacinus fungal keratitis, oral voriconazole and topical antifungal therapy were started. Despite antifungal therapy, progressive disease required therapeutic penetrating keratoplasty. Postoperatively, because of clinical signs of recurrence and in vivo confocal microscopy findings of presumed hyphae in the cornea, intracameral miconazole was injected and oral posaconazole was started. The patient improved and demonstrated no hyphae 6 weeks after starting posaconazole. When posaconazole was stopped, the cornea remained clear with excellent acuity. However, because of acute graft rejection 2 months after stopping posaconazole, keratoprosthesis was implanted, with no evidence of infection at surgery or during the 3.5-year follow-up. CONCLUSIONS: To the best of our knowledge, this is the first report on the use of oral posaconazole for Paecilomyces keratitis. Posaconazole might be indicated in the treatment of refractory Paecilomyces keratitis that is resistant to conventional therapy.