The Wholesome Foods Approach to Trabeculectomy Wet Lab Training.

Purpose In an era when trabeculectomy surgeries in the United States are on the decline, ophthalmology residents may have limited opportunities to practice surgical techniques critical to success. However, key steps of trabeculectomy surgery can be introduced in a wet laboratory using a simple surgical model based on food items. Methods A fresh lime and chicken parts with skin, purchased from a grocery store, were utilized to practice trabeculectomy surgery. The white rind of a lime was used as a surrogate for human sclera and was incised to create a trabeculectomy flap. The flap was then successfully sewn down with 10-0 nylon suture using an operating microscope. The skin of the chicken part was used to re-create a fornix-based and limbus-based conjunctival incision, which was then sutured closed using 6-0 Vicryl suture. A survey of wet laboratory participants was conducted to assess the feasibility and efficacy of this technique. Results Survey respondents were divided into two groups, those who had performed ≥40 incisional glaucoma surgeries and those who had performed <40. Both groups rated the simulation a 4 (mode) out of 5 in terms of how well it prepared them for glaucoma surgery on a human eye and how well the materials replicated human tissue, with 1 being not at all and 5 being very well. Similarly, both groups rated ease of setup and material acquisition a 1 out of 5, 1 being not difficult at all and 5 being extremely difficult. Also, 93.5% of the survey respondents recommended implementing this training model at other teaching hospitals, and none of the respondents recommended against it. Conclusion This trabeculectomy teaching model is inexpensive, clean, and safe, and it provides a reasonably realistic substrate for surgical practice. It does not require cadaver or animal eyes, and no fixatives are needed, thus minimizing the risk of contact with biohazardous materials. Wet laboratory materials are easy to obtain, making this a practical model for practicing glaucoma surgery in both westernized and developing countries.

Perimetry, retinal nerve fiber layer thickness and papilledema grade after cerebrospinal fluid shunting in patients with idiopathic intracranial hypertension.

BACKGROUND: To investigate the effect of cerebrospinal fluid (CSF) shunting on quantitative perimetry and papilledema in patients with uncontrolled idiopathic intracranial hypertension (IIH). METHODS: We retrospectively reviewed all cases of IIH with CSF shunting at our institution between 2004 and 2011. Perimetry was performed before and after surgery in 15 patients, and the mean deviation (MD) was compared before and after surgery to assess the effect of the intervention. RESULTS: Fourteen of the IIH patients were female and 1 was male. The average age was 34 years. CSF shunting resulted in significant improvement in the perimetric results with an increase in the MD of 5.63 ± 1.19 dB (P < 0.0001). Additionally, average retinal nerve fiber layer (RNFL) thickness measurement by optical coherence tomography decreased by 87.27 ± 16.65 µm (P < 0.0001), and Frisen papilledema grade decreased by 2.19 ± 0.71 (P < 0.0001). CONCLUSIONS: Our results suggest that CSF shunting results in improvement in perimetry, RNFL swelling, and papilledema grade in patients with IIH.

Patient characteristics associated with artifacts in Spectralis optical coherence tomography imaging of the retinal nerve fiber layer in glaucoma.

PURPOSE: To determine patient factors and eye conditions associated with artifacts in Spectralis optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) scans. DESIGN: Retrospective cross-sectional study. METHODS: The prevalence of 12 artifact types were described in this review of 2313 eye scans from 1188 patients who underwent a complete eye examination with Spectralis OCT scanning during the period of September 2009 to July 2013. The generalized estimating equations model was used to analyze associations between increased artifact prevalence and 10 patient characteristics, which included age, sex, race, visual acuity, refractive error, astigmatism, cataract status, glaucoma staging, visual field reliability, and glaucoma diagnosis. RESULTS: A total of 1070 or 46.3% of the 2313 eye scans had at least 1 artifact. Decentration error was the most common artifact (27.8%), followed by posterior vitreous detachment artifacts (14.4%). Visual acuity of less than 20/40 (P < .0001), presence of moderate to severe cataracts (P < .0001), advanced stage of glaucoma (P < .0001), and a diagnosis of open-angle glaucoma (P = .0003) were associated with increased prevalence of artifacts. CONCLUSIONS: Clinicians should first assess scans for artifacts before making therapeutic decisions based on RNFL thickness measurements.

Diagnostic capability of peripapillary retinal thickness in glaucoma using 3D volume scans.

PURPOSE: To determine the diagnostic capability of spectral-domain optical coherence tomography (SD OCT) peripapillary retinal thickness (RT) measurements from 3-dimensional (3D) volume scans for primary open-angle glaucoma (POAG). DESIGN: Cross-sectional study. METHODS: setting: Institutional. study population: 156 patients (89 POAG and 67 normal subjects). observation procedures: One eye of each subject was included. SD OCT peripapillary RT values from 3D volume scans were calculated for 4 quadrants of 3 different sized annuli. Peripapillary retinal nerve fiber layer (RNFL) thickness values were also determined. main outcome measures: Area under the receiver operating characteristic curve (AUROC) values, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. RESULTS: The top 5 RT AUROCs for all glaucoma patients and for a subset of early glaucoma patients were for the inferior quadrant of outer circumpapillary annulus of circular grid (OCA) 1 (0.959, 0.939), inferior quadrant of OCA2 (0.945, 0.921), superior quadrant of OCA1 (0.890, 0.811), inferior quadrant of OCA3 (0.887, 0.854), and superior quadrant of OCA2 (0.879, 0.807). Smaller RT annuli OCA1 and OCA2 consistently showed better diagnostic performance than the larger RT annulus OCA3. For both RNFL and RT measurements, best AUROC values were found for inferior RT OCA1 and OCA2, followed by inferior and overall RNFL thickness. CONCLUSION: Peripapillary RT measurements from 3D volume scans showed excellent diagnostic performance for detecting both glaucoma and early glaucoma patients. Peripapillary RT values have the same or better diagnostic capability compared to peripapillary RNFL thickness measurements, while also having fewer algorithm errors.

Pediatric internuclear ophthalmoplegia.

BACKGROUND: Internuclear ophthalmoplegia (INO) is a rare eye movement disorder in the pediatric population. METHODS: We performed a retrospective review at a university-based tertiary referral ophthalmology practice from 2004 to 2012 to identify pediatric patients with INO. RESULTS: Three patients with INO were identified. Etiologies included high-grade astrocytoma, perinantal hypoxia and neonatal intracerebral hemorrhage. One of our patients, a 2 year-old girl, is the youngest reported case of INO. CONCLUSION: While rare, INO in a pediatric patient requires a full neurologic evaluation and careful follow-up to assess eye position and potentially treat amblyopia.

No formation of DNA double-strand breaks and no activation of recombination repair with UVA.

Longwave UVA is an independent class I carcinogen. A complete understanding of UVA-induced DNA damage and how this damage is processed in skin cells is therefore of utmost importance. A particular question that has remained contentious is whether UVA induces DNA double-strand breaks (DSBs), either directly or through processing of other types of DNA damage, such as recombination repair of replication forks stalled at DNA photoproducts. We therefore studied activation of the recombination repair pathway by solar available doses of UVA and assessed formation of DNA DSBs in primary skin fibroblasts. We found that, unlike ionizing radiation or UVB, UVA does not activate the Fanconi anemia/BRCA DNA damage response pathway or the "recombinase" RAD51 in primary skin fibroblasts. The fact that this pathway mediates recombination repair of DNA DSBs suggests that DNA DSBs are not formed by UVA. This is further supported by findings that UVA did not induce DNA DSBs, as assayed by neutral single-cell electrophoresis or by formation of γ-H2AX nuclear foci, considered the most sensitive assay for DNA DSBs. The lack of sufficient evidence for formation of DNA DSBs underlines the pivotal role of UVA-induced DNA photoproducts in UVA mutagenesis and carcinogenesis.