Temporal Fat Pad Volume in Patients With Thyroid Eye Disease.

PURPOSE: To determine whether thyroid eye disease (TED) is associated with a change in temporal fossa soft tissue volume. METHODS: CT imaging studies were selected from patients with TED considering orbital decompression surgery and from an age-matched group of controls presenting to the Emergency Department for nontraumatic conditions requiring CT imaging. Measurements of the temporal fossa fat pad and soft tissue thickness were used as a proxy for volume and were performed using the zygomaticotemporal suture as a reference point. Categorical variables were described using frequencies and percentages, while continuous variables were described using medians and standard deviations. Chi-square tests were used to assess the relationship between gender and age group, while t-tests were used to examine the relationship between continuous variables and age group. RESULTS: A total of 56 CT scans were evaluated, including scans from 28 patients with TED and 28 controls. The following measurements were found to be significantly larger in the TED population: left fat pad measured 5 mm above the zygomaticotemporal suture (p = 0.012), right fat pad measured 15 mm above the suture (p = 0.005), right soft tissue measured 15 mm above the suture (p = 0.026), left fat pad measured 15 mm above the suture (p = 0.006), and the left soft tissue measure 15 mm above the suture (p = 0.032). CONCLUSIONS: Thyroid eye disease is associated with an increase in temporal fossa fat pad and soft tissue volume. These findings suggest that TED disease may produce pan-facial changes rather than changes confined to the peri-orbital region.

Comparative outcomes and toxicities for ruthenium-106 versus palladium-103 in the treatment of choroidal melanoma.

For the treatment of choroidal melanoma, palladium-103 (Pd) and ruthenium-106 (Ru) plaque brachytherapy shows reduced toxicity compared with the historical standard iodine-125. No report has directly compared the clinical outcomes between Pd and Ru, and the reasons for the selection of one over the other remain purely theoretical. Patients with choroidal melanoma with apical tumor height up to 5 mm were included. Patients from Emory University were treated with Pd between 1993 and 2012. Patients from Cleveland Clinic were treated with Ru between 2005 and 2010. Medical records were retrospectively reviewed. We compared post-treatment visual acuity (VA), toxicity, and oncologic outcomes. Pd patients (n=124) and Ru patients (n=42) had a median follow-up of 4.2 and 5.0 years, respectively. Radiation retinopathy-free survival was similar for both radioisotopes, but Ru had lower grades of retinopathy (P=0.006). Pd was associated with worse VA preservation (≥20/40) by year 3 (odds ratio: 3.8; 95% confidence interval: 1.01-14.31, P=0.048). Pd was associated with higher distant metastases-free survival (DMFS) in multivariate analysis (hazard ratio: 0.10; 95% confidence interval: 0.02-0.38; P<0.001). Ru had lower grades of radiation retinopathy and improved long-term VA preservation, but also inferior DMFS, compared with Pd. Because of the inherent limitations of a retrospective analysis, the significance of the inferior DMFS for Ru remains unclear, although the suggestion of a slight inferiority in terms of DMFS for Ru is consistent with the other limited literature. On the basis of this study, we believe that both radioisotopes remain appropriate for the treatment of small choroidal melanomas up to 5 mm in apical height.

Hepatic Ultrasonography for Surveillance in Patients With Uveal Melanoma.

IMPORTANCE: There is a lack of information regarding the role of systemic surveillance in patients with primary uveal melanoma. OBJECTIVE: To evaluate the utility of serial hepatic ultrasonography (USG) for detection of asymptomatic liver metastases in patients undergoing surveillance after primary treatment of uveal melanoma. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study reviewing data from patients with primary uveal melanoma treated between October 2003 and October 2012 at a multispecialty tertiary care center. Patients were managed using a standardized protocol. Initial staging was done with contrast-enhanced computed tomography of the chest, abdomen, and pelvis. This was followed by periodic surveillance with hepatic USG and liver function tests scheduled every 6 months for the first 5 years and annually thereafter. Abnormal surveillance hepatic USG findings were categorized as (1) cyst or hemangioma, (2) indeterminate lesion, (3) suspicious for metastasis, or (4) consistent with metastasis. If indicated, hepatic USG abnormalities were confirmed by additional imaging modalities (confirmatory scans) such as computed tomography or magnetic resonance imaging. Liver biopsy was performed only if the confirmatory scan was positive. MAIN OUTCOMES AND MEASURES: Sensitivity, specificity, and positive predictive value of hepatic USG for detecting asymptomatic liver metastases. RESULTS: In 263 patients (121 men, 142 women; mean [SD] age at diagnosis, 61.1 [13.9] years), a total of 1390 hepatic USGs were performed, with a mean of 5.3 per patient (range, 1-17 per patient). Overall, 86 hepatic USGs of 71 patients (27%) were reported as abnormal. Of the 13 lesions identified as a cyst/hemangioma and 17 as indeterminate, 1 was found to be metastatic in each group (8% and 6%, respectively). Of 36 patients with findings suspicious for metastasis, 23 (64%) had metastasis confirmed. All 5 patients (100%) with findings consistent with metastasis had biopsy-proven metastasis. The sensitivity, specificity, and positive predictive value of hepatic USG for findings that were indeterminate or suspicious for metastasis were 96% (95% CI, 80%-99%), 88% (95% CI, 83%-91%), and 45% (95% CI, 33%-59%), respectively. Specificity of the confirmatory scan was greater than that of hepatic USG (93% [95% CI, 89%-96%] vs 88% [95% CI, 83%-91%], respectively; P < .001). Only 4 of 30 patients (13%) with metastasis had abnormal findings on simultaneous liver function tests. CONCLUSIONS AND RELEVANCE: A stepwise surveillance protocol based on serial hepatic USGs followed by confirmatory scans offers high likelihood of detecting asymptomatic metastases in patients with primary uveal melanoma.

Globe Loss From Intraocular Invasion of MIRAgel Scleral Buckle Components.

PURPOSE: To describe intraocular invasion of MIRAgel scleral buckles requiring evisceration. METHODS: This is an Institutional Review Board-approved retrospective consecutive case series of eyes requiring evisceration secondary to intraocular intrusion of MIRAgel implants performed at the Cole Eye Institute from 2000 to 2014. Charts were reviewed for age at surgery, gender, laterality, time between MIRAgel placement and evisceration, preoperative examination and imaging results, intraoperative findings, postoperative complications, and duration of follow up. RESULTS: Five eyes of 5 patients underwent evisceration due to a blind, painful eye secondary to MIRAgel expansion. The mean time between MIRAgel placement and evisceration was 21 years (range: 17-30 years). Preoperative ultrasound identified intraocular MIRAgel in 3 of 5 cases; however, intraocular MIRAgel was identified during surgery in all 5 cases. A transocular-approach orbitotomy was performed at the time of evisceration in an effort to remove the MIRAgel. Postoperative complications included ptosis and inability to retain an ocular prosthesis. No cases of orbital implant extrusion occurred. CONCLUSION: Scleral invasion and intraocular penetration of MIRAgel may occur decades after placement. This may result in a blind, painful eye requiring evisceration and orbitotomy to remove residual material. Suspicion of intraocular penetration of implant should be high in blind, painful eyes. Surgical removal can be difficult due to MIRAgel fragmentation. Conjunctival insufficiency may result in the need for further surgery after evisceration.

Frontalis Muscle Asymmetry and Lateral Landmarks.

PURPOSE: To investigate frontalis muscle asymmetry and characterize its lateral interdigitation with the orbicularis oculi muscle. METHODS: After making a mid-coronal incision and bluntly dissecting to the orbital rim, the frontalis muscle was exposed, marked, and photographed. The right and left muscle bellies were analyzed and compared in both pixels and cm ratios generated with NIH ImageJ software. A ratio of ≥1.5 was considered significantly asymmetric. The lateral interdigitation of the frontalis and orbicularis oculi muscles was measured from the supraorbital notch with a metric ruler. Data were analyzed using 2-sample t tests, paired t tests, log scales, and nonparametric tests were performed for sensitivity analyses. A p value of ≤0.05 was considered statistically significant. RESULTS: Fifty-eight hemifaces of 29 Caucasian cadavers were studied for muscle belly asymmetry. Thirty-six hemifaces of 18 Caucasian cadavers (9 males) were dissected for lateral landmarks and average age of these specimens was 73 years (range: 35-91 years). Significant asymmetry in muscle belly area was found in 6/29 (20%) specimens, with the right muscle belly larger in all 6 specimens. On average, the right muscle belly area was 1.23 times that of the left (p = <0.001). The average frontalis-orbicularis interdigitation occurred 3.4 cm lateral to the supraorbital notch. CONCLUSIONS: Significant frontalis muscle belly asymmetry exists in 20% of Caucasians cadavers. The right muscle belly was larger on average and in all cases of significant asymmetry. The frontalis muscle interdigitates with the orbicularis oculi on average 3.4 cm lateral to the supraorbital notch.

Neovascular Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is the leading cause of severe vision loss in individuals over the age of 50 years. Choroidal neovascularization (CNV) is the hallmark of 'wet' or 'exudative' AMD, and is responsible for approximately 90% of cases of severe vision loss due to AMD. Vascular endothelial growth factor (VEGF) is a key component in the development and progression of wet AMD. Since the approval of ranibizumab in 2006, VEGF inhibitors have rapidly altered the treatment and standard of care for wet AMD. Ranibizumab, bevacizumab, and aflibercept are now the most widely used anti-VEGF agents for the treatment of wet AMD. This chapter discusses the pharmacologic properties, pharmacokinetics, safety, and efficacy of these medications, as well as revisits landmark clinical trials that establish these drugs as gold standards in care. While these medications have greatly and positively altered the way we treat AMD, there are still many economic and therapeutic limitations with our current therapy regimens. There continue to be advancements and innovations in exploring alternative and new treatment modalities, as well as combining existing treatment options to improve efficacy, and reduce cost and patient burden.

Eyelid Contour Following Conjunctival Müllerectomy With or Without Tarsectomy Blepharoptosis Repair.

PURPOSE: To quantitatively determine how accurately conjunctival Müllerectomy with or without tarsectomy (CM ± T) blepharoptosis repair restores eyelid contour. METHODS: The charts of all patients undergoing unilateral CM ± T blepharoptosis repair at the Cole Eye Institute between June 2012 and September 2014 were reviewed. Preoperative and postoperative digital images were used for eyelid contour analysis. Eyelid contour was measured according to a previously described technique measuring 13 radial mid-pupil eyelid distances (MPLDs) in pixels at 15° intervals from 0° to 180°. Eyelid contour was computed taking the ratio of the corresponding radial MPLD on either side of margin reflex distance (105/75, 120/60, 135/45, 150/30, 165/15, and 180/0) using ImageJ software (National Institutes of Health, Bethesda, MD). Ratios were compared between the preoperative and postoperative images using paired t test with statistical significance set at p < 0.05. RESULTS: One hundred and six cases of unilateral CM ± T were performed during the study period and 20 cases met inclusion criteria. In the ptotic eyelid, the postoperative eyelid and the unoperated eyelid groups, the average temporal-to-nasal MPLD ratios at corresponding angles from the midline were closer to 1 from 45° to 135°. Then, further from the midline, at more obtuse angles, the temporal MPLD was greater than the nasal MPLD (i.e., the ratio was greater than 1) in all 3 groups. CONCLUSIONS: There was no significant difference in any corresponding MPLD or temporal/nasal MPLD ratio between the postoperative eyelid and the postoperative control eyelid. This technique for CM ± T blepharoptosis repair adequately restores eyelid contour.

Gender and ocular manifestations of connective tissue diseases and systemic vasculitides.

Ocular manifestations are present in many connective tissue diseases which are characterized by an immune system that is directed against self. In this paper, we review the ocular findings in various connective tissue diseases and systemic vasculitides and highlight gender differences in each disease. In rheumatoid arthritis, we find that dry eyes affect women nine times more than men. The other extra-articular manifestations of rheumatoid arthritis affect women three times more commonly than men. Systemic lupus erythematosus can involve all ocular structures and women are nine times more affected than men. Systemic sclerosis is a rare disease but, again, it is more common in women with a female to male ratio of 8 : 1. Polymyositis and dermatomyositis also affect women more commonly than men but no gender differences have been found in the incidence or disease course in the systemic vasculitides associated with antineutrophil cytoplasmic antibody such as granulomatosis with polyangiitis (GPA, formerly known as Wegener's granulomatosis). Finally, Behcet's disease is more common in males, and male gender is a risk factor for Behcet's disease. There is a slight female preponderance in sarcoidosis with female gender carrying a worse prognosis in the outcome of ocular disease.

Elevated immunoglobulin G4 level is associated with reduced colectomy-free survival in patients with primary sclerosing cholangitis and ulcerative colitis.

BACKGROUND AND AIM: Patients with primary sclerosing cholangitis (PSC) and elevated immunoglobulin (Ig) G4 have been shown to have more severe disease with a shorter time to orthotopic liver transplantation (OLT). The aim of the study was to investigate the clinical outcomes of PSC and UC in patients with elevated serum IgG4. METHODS: We analyzed data from 50 patients with PSC and known serum levels of IgG4. They were divided into groups called high IgG4 (>112 IU/L; n = 10) or normal IgG4 (n = 40). We compared the requirement of OLT and colectomy between groups. RESULTS: High IgG4 was found in 10 PSC patients (20%). UC was associated in 9/10 patients with high IgG4 vs. 32/40 patients with normal IgG4 (p=0.67). Patients with high IgG4 were younger at PSC diagnosis (28.1 ± 13.9 vs. 37.6 ± 13.4 years, P=0.04), more likely to have backwash ileitis (7/9 vs. 12/32, P < 0.001) and UC flares (median of 5.5 vs. 1.5, P = 0.02). Kaplan-Meier curve analysis showed that patients with elevated IgG4 had reduced colectomy-free survival than patients with normal IgG4 (Log Rank p < 0.001). The median time to colectomy was 5 years from UC diagnosis in high IgG4 group vs. 12 years in the normal IgG4 group (p = 0.01). CONCLUSIONS: Elevated IgG4 was seen in a small number of PSC patients. Most of these patients had associated UC, were younger at the time of PSC diagnosis, more likely to have backwash ileitis and had reduced colectomy-free survival than patients with normal IgG4.

Removal of silicone oil: prognostic factors and incidence of retinal redetachment.

PURPOSE: To evaluate the incidence of retinal redetachment after the removal of silicone oil endotamponade for complicated retinal detachment and identify possible factors affecting outcome. METHODS: This is a retrospective review of 173 patients who underwent pars plana vitrectomy with silicone oil tamponade for complex retinal detachment and subsequent removal of silicone oil (ROSO). The outcome factors studied included anatomical success, best-corrected visual acuity and intraocular pressure pre- and post-ROSO. RESULTS: Anatomical success was achieved in 167 of the 173 eyes (96.5%) after ROSO. The mean duration of silicone oil tamponade was 70 ± 48 weeks (median, 56 weeks; mode, 48 weeks). The cause for primary retinal detachment was proliferative diabetic retinopathy in 36 (20.8%) and proliferative vitreoretinopathy in 137 of 173 cases (79.2%). Best-corrected visual acuity of greater than 20/100 was achieved in 83 cases (49.4%) at 3 months after ROSO. Levene's test for equality of variances was used to determine the association between previous unsuccessful retinal surgeries and redetachment (P = 0.523) and between duration of endotamponade and anatomical success (P = 0.451). CONCLUSION: The incidence of retinal redetachment after ROSO in our study was 3.46%. Aggressive removal of the vitreous base, performing retinotomies, ensuring complete silicone oil filling for adequate tamponade, and argon retinopexy can lead to low complication rates and improved outcomes.

Tubulinosema sp. microsporidian myositis in immunosuppressed patient.

The Phylum Microsporidia comprises >1,200 species, only 15 of which are known to infect humans, including the genera Trachipleistophora, Pleistophora, and Brachiola. We report an infection by Tubulinosema sp. in an immunosuppressed patient.

Awareness and perceptions of electroconvulsive therapy among psychiatric patients: a cross-sectional survey from teaching hospitals in Karachi, Pakistan.

BACKGROUND: Electroconvulsive therapy (ECT) is shown to be effective in many psychiatric illnesses, but its distorted projection by the Pakistani media and its unregulated use by many physicians across the country have adversely affected its acceptability. Given this situation we aimed to assess the awareness and perceptions regarding ECT as a treatment modality among the psychiatric patients. METHODS: This was a questionnaire based cross-sectional study carried out at 2 tertiary care hospitals in Karachi, Pakistan. RESULTS: We interviewed 190 patients of which 140 were aware of ECT. The study showed that the level of education had a significant impact on the awareness of ECT (p = 0.009). The most common source of awareness was electronic and print media (38%), followed by relatives (24%) and doctors (23%). Physical injuries (42%) and neurological (12%) and cognitive disturbances (11%) were the commonly feared side effects. The most popular belief about ECT was that it was a treatment of last resort (56%). Thirty-nine percent thought that ECT could lead to severe mental and physical illness and 37% considered it inhumane. Patients' willingness to receive ECT was dependant on whether or not they were convinced of its safety (p = 0.001) and efficacy (p = 0.0001). CONCLUSION: We identified a serious lack of dissemination of information regarding ECT by the psychiatrists and the mental health care providers. This may be the result of an inadequate postgraduate training in Pakistan or just a lack of concern about the mentally ill patients. The media seemed to be the major source of information for our patients. We also saw the prevalence of a variety of myths regarding ECT in our society, which we feel may be responsible for the patients' adverse attitudes. Given the widespread applicability of ECT there is a dire need to dispel these misconceptions and improve its acceptability.