Incidence, Management, and Surgical Outcomes of Macular Splitting Rhegmatogenous Retinal Detachment.

BACKGROUND AND OBJECTIVE: Limited knowledge exists regarding macular splitting retinal detachment (RD). The purpose of this study is to investigate clinical features and outcomes of macular splitting RD. PATIENTS AND METHODS: This was a retrospective case series performed at a single practice. Macular splitting RD was identified clinically and on optical coherence tomography (OCT). Primary outcomes were anatomical and functional success, and secondary outcomes were factors associated with postoperative visual acuity. RESULTS: The overall number of patients with OCT-confirmed macular splitting RD was 16 of 664, which is an incidence rate of 2.4%. Preoperative and final logMAR were 0.33 and 0.13, respectively (P = .002). Presenting visual acuity (VA) (P = 0.015) and duration of symptoms (P = .007) were associated with final VA, whereas time to surgery was not significant (P = .581). CONCLUSION: The incidence of macular splitting RD is higher than previously reported. Anatomical and functional outcomes were excellent in this study. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:602-608.].

Pars Plana Vitrectomy Outcomes for Rhegmatogenous Retinal Detachment Qualifying for Pneumatic Retinopexy.

PURPOSE: To investigate real-world outcomes of pars plana vitrectomy (PPV) for eyes with primary rhegmatogenous retinal detachments (RRD) eligible for pneumatic retinopexy (PnR). METHODS: This was a single center retrospective case series looking at consecutive patients with primary RRDs. A database was created on all patients with a primary RRD from 2010 to 2018 based on billing code 67108. Eyes anatomically eligible for PnR were reviewed for preoperative, intraoperative and postoperative characteristics. The main outcome assessed was single surgery anatomical success (SSAS), final anatomical success (FAS), and postoperative LogMAR vision. RESULTS: A total of 720 eyes (age, 62.9 ± 9.1 years; 61.7% were male) met inclusion criteria for PnR and underwent PPV. SSAS was 94.0% and FAS was 99.9%. Preoperative and final LogMAR vision was 0.853 and 0.293 (P<0.001) in eyes with SSAS vs 0.714 and 0.648 (P=0.686) in eyes with primary failure. PVR was the most common etiology of primary surgical failure (n=21, 49%). Patients who failed primary repair had a mean of 1.12 additional surgeries with a median time of 45 days between surgeries. CONCLUSION: A robust single surgery success rate with good visual outcomes was achieved across 8 years and multiple surgeons utilizing PPV to treat primary RRDs in eyes which anatomically qualified for pneumatic retinopexy in a real-world setting.

Evaluation of Spin in the Abstracts of Emergency Medicine Randomized Controlled Trials.

STUDY OBJECTIVE: We aim to investigate spin in emergency medicine abstracts, using a sample of randomized controlled trials from high-impact-factor journals with statistically nonsignificant primary endpoints. METHODS: This study investigated spin in abstracts of emergency medicine randomized controlled trials from emergency medicine literature, with studies from 2013 to 2017 from the top 5 emergency medicine journals and general medical journals. Investigators screened records for inclusion and extracted data for spin. We considered evidence of spin if trial authors focused on statistically significant results, interpreted statistically nonsignificant results as equivalent or noninferior, used favorable rhetoric in the interpretation of nonsignificant results, or claimed benefit of an intervention despite statistically nonsignificant results. RESULTS: Of 772 abstracts screened, 114 randomized controlled trials reported statistically nonsignificant primary endpoints. Spin was found in 50 of 114 abstracts (44.3%). Industry-funded trials were more likely to have evidence of spin in the abstract (unadjusted odds ratio 3.4; 95% confidence interval 1.1 to 11.9). In the abstracts' results, evidence of spin was most often due to authors' emphasizing a statistically significant subgroup analysis (n=9). In the abstracts' conclusions, spin was most often due to authors' claiming they accomplished an objective that was not a prespecified endpoint (n=14). CONCLUSION: Spin was prevalent in the selected randomized controlled trial, emergency medicine abstracts. Authors most commonly incorporated spin into their reports by focusing on statistically significant results for secondary outcomes or subgroup analyses when the primary outcome was statistically nonsignificant. Spin was more common in studies that had some component of industry funding.

The Results of Randomized Controlled Trials in Emergency Medicine Are Frequently Fragile.

STUDY OBJECTIVE: Randomized controlled trials govern evidence-based clinical practice, and it is therefore critical that their results be robust. We aim to investigate the fragility of randomized controlled trials in emergency medicine by determining how often significance would be nullified with small changes in outcomes using the fragility index. METHODS: We conducted a methodological systematic review of randomized controlled trials in emergency medicine published in the top 10 general medicine journals and the top 10 emergency medicine journals. Inclusion criteria required that trials be emergency medicine studies structured with a 2-arm or 2-by-2 factorial design and report at least 1 statistically significant dichotomous outcome. RESULTS: A total of 180 trials met inclusion criteria. The median fragility index across all trials in emergency medicine was 4 (interquartile range [IQR] 2 to 10) and the median sample size was 140 (IQR 69.5 to 286). For trials from general medicine journals (n=32), the median fragility index was 9 (IQR 4 to 16.5) and the median sample size was 415.5 (IQR 219.5 to 901); for trials from emergency medicine journals (n=148), the median fragility index was 4 (IQR 1 to 9) and the median sample size was 119 (IQR 60 to 227.25). One third of all trials (62/180) had a loss to follow-up that was greater than or equal to the fragility index. There was a modest correlation between fragility index and total number of events (r=0.36; 95% confidence interval [CI] 0.23 to 0.48) and a weak correlation between fragility index and total sample size (r=0.26; 95% CI 0.12 to 0.39). There was no correlation between fragility index and either P value (r=-0.14; 95% CI -0.28 to -0.006) or Science Citation Index (r=0.07; 95% CI -0.08 to 0.22). CONCLUSION: The statistical significance of the results of randomized controlled trials in emergency medicine was often contingent on a small number of events. Until frequentist interpretation of clinical trials is replaced with Bayesian analysis, the fragility index may have utility as a tool to aid clinicians in assessing the robustness of randomized controlled trials in emergency medicine when considered in conjunction with the fragility quotient and other reported metrics.

Mps1 promotes chromosome meiotic chromosome biorientation through Dam1.

In budding yeast meiosis, homologous chromosomes become linked by chiasmata and then move back and forth on the spindle until they are bioriented, with the kinetochores of the partners attached to microtubules from opposite spindle poles. Certain mutations in the conserved kinase, Mps1, result in catastrophic meiotic segregation errors but mild mitotic defects. We tested whether Dam1, a known substrate of Mps1, was necessary for its critical meiotic role. We found that kinetochore-microtubule attachments are established even when Dam1 is not phosphorylated by Mps1, but that Mps1 phosphorylation of Dam1 sustains those connections. But the meiotic defects when Dam1 is not phosphorylated are not nearly as catastrophic as when Mps1 is inactivated. The results demonstrate that one meiotic role of Mps1 is to stabilize connections that have been established between kinetochores and microtubles by phosphorylating Dam1.

Increased Reoperation Rate in Surgical Treatment of Rhegmatogenous Retinal Detachment with Coexistent Macular Hole.

PURPOSE: To examine the surgical outcomes in patients with coexistent macular hole (MH) and rhegmatogenous retinal detachment (RRD). DESIGN: Retrospective case series. PARTICIPANTS: All patients who underwent surgical repair of concomitant MH and retinal detachment (MHRD) between January 2014 and December 2016 in our facility were examined. At least 1 retinal break was noted in all MHRD cases. Exclusion criteria included MHRD related to high myopia without peripheral retinal tears. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Data collected included presence of proliferative vitreoretinopathy (PVR) and classification at time of surgical repair, details of surgical repair including whether internal limiting membrane (ILM) peeling was achieved, type of ILM staining used, presence of retinal detachment (RD) in the fellow eye, and duration of follow-up. Outcomes evaluated included visual acuity comparisons, reoperation rate, final anatomic success, and MH closure rate. RESULTS: Over the study period, MHRD cases accounted for 17 of 745 (2.3%) of all repaired RDs in our practice. Proliferative vitreoretinopathy was present in 53% of MHRD cases. Reoperation rates for MHRD were significantly higher than our practice average for all RD repairs (29% vs. 9.7%; P = 0.01). Final anatomic success with RD was achieved in 100% of patients. Internal limiting membrane peeling was performed in 15 of 17 patients. Macular hole closure rate was 71% after initial surgery. Although 82% of patients experience equal or improved vision, only 24% of patients achieved visual acuity better than 20/80. Retinal detachment in the contralateral eye was noted in 3 of 16 patients (19%) included before initial presentation or during the follow-up period. CONCLUSIONS: Visual outcomes in MHRD cases were underwhelming because of high rates of presentation with PVR macula-off RRD, high reoperation rates, and relatively low MH closure rates. We suggest aggressive surgical techniques to repair MHRD.

Correlation of outer retinal microstucture and foveal thickness with visual acuity after pars plana vitrectomy for complications of proliferative diabetic retinopathy.

PURPOSE: To compare spectral domain optical coherence tomography (SDOCT)-measured macular thickness, outer retinal layers architecture, and best-corrected visual acuity (BCVA) in eyes with proliferative diabetic retinopathy after pars plana vitrectomy. METHODS: In this retrospective case study, consecutive eyes operated by single surgeon were included. Retinal thickness was measured with SDOCT (Cirrus OCT; Carl Zeiss Meditec, Inc) as follows: automated central 1-mm subfield thickness (CFT), manually measured central foveal point thickness (CPT), integrity of external limiting membrane (ELM), and photoreceptor inner and outer segments (IS/OS). Three vitreoretinal-trained masked experts independently graded ELM and IS/OS layers. RESULTS: Of the 36 eyes included, 50% were those of women whose mean age was 49 years (range, 24-66 years). Mean preoperative BCVA was 20/600 (range, light perception to 20/80) and mean postoperative follow-up was 19 months (range, 4-43 months). Mean postoperative BCVA improved to 20/80 (range, counting fingers to 20/25; P < 0.0001) with mean SDOCT 1 mm CFT of 260 µm and manual CPT of 236 µm. Mean ELM integrity grade was 1.9 (range, 0-5), while the mean grade of IS/OS integrity was 2.2 (range, 0-5). The correlation coefficients (r) were 0.17 (P = 0.32) for logarithm of the minimum angle of resolution BCVA versus SDOCT automated CFT, 0.192 (P = 0.26) for BCVA versus SDOCT CPT, 0.52 (P = 0.012) for BCVA versus ELM, and 0.55 (P = 0.006) for BCVA versus IS/OS. CONCLUSION: SDOCT-measured CFT and CPT correlate weakly with BCVA, while ELM and IS/OS integrity correlates well with BCVA. Outer retinal microstructure may represent anatomically better level of postoperative visual function than retinal thickness after pars plana vitrectomy for complications of proliferative diabetic retinopathy.

Anticoagulation and clinically significant postoperative vitreous hemorrhage in diabetic vitrectomy.

PURPOSE: The purpose of this study was to provide further information about the risks of perioperative hemorrhage in diabetic vitrectomy in patients on anticoagulation. This may help us to better understand more about the fine balance between the risks of stopping anticoagulation versus continuation for intraocular surgery. METHODS: A retrospective, comparative cohort study of all patients undergoing a diabetic pars plana vitrectomy by a single surgeon over a 30-month period at a single institution was conducted. RESULTS: Ninety-seven eyes were included for analysis. Twenty-seven eyes remained on anticoagulation during the surgery. There were no perioperative complications related to the anticoagulation. Surgical intervention resulted in a significant increase in visual acuity in both groups. There was no difference in the incidence of postoperative vitreous hemorrhage or surgical reoperation between the two groups. Patients on anticoagulation had significantly worse postoperative vision compared with those not on anticoagulation (best-corrected visual acuity of 20/230 vs. 20/100, P = 0.03). CONCLUSION: Patients undergoing diabetic vitrectomy, who are on anticoagulation or antiplatelet agents, do not exhibit a higher risk of intraoperative or postoperative vitreous hemorrhage. Anticoagulants and antiplatelets may be safely continued perioperatively to avoid complications secondary to their systemic disease.

In vivo human choroidal thickness measurements: evidence for diurnal fluctuations.

PURPOSE: The authors applied partial coherence interferometry (PCI) to estimate the thickness of the human choroid in vivo and to learn whether it fluctuates during the day. METHODS: By applying signal processing techniques to existing PCI tracings of human ocular axial length measurements, a signal modeling algorithm was developed and validated to determine the position and variability of a postretinal peak that, by analogy to animal studies, likely corresponds to the choroidal/scleral interface. The algorithm then was applied to diurnal axial eye length datasets. RESULTS: The postretinal peak was identified in 28% of subjects in the development and validation datasets, with mean subfoveal choroidal thicknesses of 307 and 293 microm, respectively. Twenty-eight of 40 diurnal PCI datasets had at least two time points with identifiable postretinal peaks, yielding a mean choroidal thickness of 426 microm and a mean high-low difference in choroidal thickness of 59.5 +/- 24.2 microm (range, 25.9-103 microm). The diurnal choroidal thickness fluctuation was larger than twice the SE of measurement (24.5 microm) in 16 of these 28 datasets. Axial length and choroidal thickness tended to fluctuate in antiphase. CONCLUSIONS: Signal processing techniques provide choroidal thickness estimates in many, but not all, PCI datasets of axial eye measurements. Based on eyes with identifiable postretinal peaks at more than one time in a day, choroidal thickness varied over the day. Because of the established role of the choroid in retinal function and its possible role in regulating eye growth, further development and refinement of clinical methods to measure its thickness are warranted.

In situ ultrahigh-resolution optical coherence tomography characterization of eye bank corneal tissue processed for lamellar keratoplasty.

PURPOSE: To use optical coherence tomography (OCT) as a noninvasive tool to perform in situ characterization of eye bank corneal tissue processed for lamellar keratoplasty. METHODS: A custom-built ultrahigh-resolution OCT (UHR-OCT) was used to characterize donor corneal tissue that had been processed for lamellar keratoplasty. Twenty-seven donor corneas were analyzed. Four donor corneas were used as controls, whereas the rest were processed into donor corneal buttons for lamellar transplantation by using hand dissection, a microkeratome, or a femtosecond laser. UHR-OCT was also used to noninvasively characterize and monitor the viable corneal tissue immersed in storage medium over 3 weeks. RESULTS: The UHR-OCT captured high-resolution images of the donor corneal tissue in situ. This noninvasive technique showed the changes in donor corneal tissue morphology with time while in storage medium. The characteristics of the lamellar corneal tissue with each processing modality were clearly visible by UHR-OCT. The in situ characterization of the femtosecond laser-cut corneal tissue was noted to have more interface debris than shown by routine histology. The effects of the femtosecond laser microcavitation bubbles on the corneal tissue were well visualized at the edges of the lamellar flap while in storage medium. CONCLUSIONS: The results of our feasibility study show that UHR-OCT can provide superb, in situ microstructural characterization of eye bank corneal tissue noninvasively. The UHR-OCT interface findings and corneal endothelial disc thickness uniformity analysis are valuable information that may be used to optimize the modalities and parameters for lamellar tissue processing. The UHR-OCT is a powerful approach that will allow us to further evaluate the tissue response to different processing techniques for posterior lamellar keratoplasty. It may also provide information that can be used to correlate with postoperative clinical outcomes. UHR-OCT has the potential to become a routine part of tissue analysis for any eye bank or centers creating customized lamellar corneal tissue for transplantation.

Barriers of and facilitators to physician recommendation of colorectal cancer screening.

BACKGROUND: Colorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS. METHODS: A 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used. RESULTS: All the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50-59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives. CONCLUSION: There are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.

Diurnal axial length fluctuations in human eyes.

PURPOSE: This study sought diurnal variations of eye length in human subjects, analogous to those reported in laboratory animals. METHODS: Seventeen subjects, ages 7 to 53 (median 16) years and mean spherical equivalent refractive error -0.68 D (range, -3.00 to +1.00 D), underwent axial length measurements at multiple times during the day between 7 AM and 1 AM the following day, using partial coherence interferometry (PCI), a highly precise, noncontact method. Diurnal axial length measurements were obtained on two or more days in 10 of these subjects. RESULTS: During at least 1 day, 15 subjects showed a statistically significant (ANOVA, P < 0.05) diurnal fluctuation of axial length, with a magnitude generally between 15 and 40 microm. From the diurnal tracings that fit a sine curve using statistical criteria, the mean period of fluctuation was 21.6 +/- 4.33 hours (SD), the mean amplitude was 27.1 +/- 11.9 microm (SD; range, 12.8-41.4 microm), and the maximum axial length tended to occur at midday. Each of the subjects with multiple daily measurements showed axial length fluctuations on at least 1 day, but there were day-to-day differences in the diurnal variations: most notably, four subjects showed axial length fluctuations on each day; in others, the fluctuations were not observed on each testing day. CONCLUSIONS: The human eye undergoes diurnal fluctuations in axial length, with a pattern suggesting maximum axial length at midday. Based on repeated measurements, these daily fluctuations may not appear regularly in all subjects, suggesting the possibility of physiologic influences that must be defined.