Effect of Preoperative Trabecular Meshwork Pigmentation and Other Eye Characteristics on Outcomes of Combined Phacoemulsification/Minimally Invasive Glaucoma Surgery.

PURPOSE: To investigate associations between pigmentation of the trabecular meshwork (PTM) and other preoperative eye characteristics and outcomes of minimally invasive glaucoma surgery combined with phacoemulsification (Phaco/MIGS). DESIGN: Retrospective interventional case series. PARTICIPANTS: Academic glaucoma clinic patients with symptomatic cataract and glaucoma treated with combined Phaco/MIGS. METHODS: Analyzing preoperative PTM, intraocular pressure (IOP), IOP-lowering medications and visual acuity (VA) data in relation to Phaco/MIGS outcomes. MAIN OUTCOME MEASURES: Pigmentation of the trabecular meshwork and other preoperative eye characteristics in relation to Phaco/MIGS success defined as postoperative IOP between 5 and 21 mmHg and IOP reduction of ≥ 20% and/or a reduction of ≥ 1 IOP-medications compared to baseline, and final IOP, IOP-lowering medications and VA. RESULTS: A total of 265 eyes (172 patients, mean age, 73.5 [standard deviation, 10.0], range 35-95 years, male 40.0%) were identified and categorized with high PTM (108 eyes, 40.8%) or low PTM (157 eyes, 59.2%). The high PTM group, compared with the low PTM group, demonstrated higher preoperative IOP (16.7 [standard error 0.4] vs. 15.2 [0.4] mmHg, P = 0.009), included more eyes with primary open-angle glaucoma (POAG, P = 0.03), fewer eyes with normal-tension glaucoma (NTG, P = 0.01), and fewer eyes with mild stage glaucoma (P = 0.001). Compared to baseline, final IOP decreased by 6.5 [2.4]% and 13.4 [3.0]% (P = 0.075) to 13.5 [0.3] mmHg and 13.6 [0.4] mmHg (P = 0.77) in the low and high PTM groups, respectively, and IOP-lowering medications decreased by 34.6 [4.9]% (n = 116) and 18.1 [7.3]% (n = 85), respectively (P = 0.062). Surgical success was 59.9% and 58.3%, respectively (P = 0.87). It was positively associated with higher preoperative IOP (hazard ratio 1.08 [95% confidence interval 1.04-1.12] P < 0.0001) and higher number of preoperative IOP-medications (1.20 [1.05-1.37] P = 0.007), negatively associated with history of selective laser trabeculoplasty (SLT, 0.40 [0.23-0.68] P = 0.0009) and longer axial length (0.87 [0.80-0.94], P = 0.0006), but was not associated with PTM. CONCLUSIONS: Higher PTM was associated with POAG rather than NTG, with more severe glaucoma and higher preoperative IOP, but not with Phaco/MIGS success. Surgical success was positively associated with higher preoperative IOP and number of IOP-medications and negatively associated with history of SLT and longer axial length. These findings may help guide glaucoma surgeons in surgical planning and patient counseling. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Risk assessment of variant Creutzfeldt-Jakob disease in corneal transplantation.

Purpose: While corneal transplantation is known to have a potential risk of transmission of variant Creutzfeldt-Jacob Disease (vCJD), the magnitude of this risk has not been quantified. Observations: A case report is presented of a 73 year-old man with a penetrating keratoplasty graft from corneal tissue that was recalled after transplantation due to risk of vCJD because it was later discovered that the donor had traveled to the United Kingdom (UK). Probabilities of vCJD transmission were extrapolated using Creutzfeldt-Jacob Disease (CJD) mortality (incidence) rate, all-cause death rate, and rate of recovery for intended transplantation. Conclusions: An overestimate of the risk of transplanting a cornea infected with vCJD in 2018 was 1 in 940,000. The true risk of vCJD transmission would be even lower due to an incomplete infectivity rate. We conclude that the risk of transmission of latent vCJD by corneal transplantation from a donor who traveled to the UK from 1980 to 1996 is exceedingly low.

Frailty and spontaneous intracerebral hemorrhage: Does the modified frailty index predict mortality?

OBJECTIVE: This study aims to elucidate the impact of frailty on spontaneous intracranial hemorrhage (SICH) patient outcomes in the United States. PATIENTS AND METHODS: This is a single center retrospective chart review of all adult patients (≥18 years old) admitted with a primary diagnosis of SICH due to hypertension, amyloid angiopathy, and coagulopathy from 2014-2017. The studied variables included length of stay, age, sex, ICH score variables, medications, and frailty as measured by the modified Frailty Index (mFI). RESULTS: A total of 240 patients with 248 SICH were included in the analysis. In this study, mFI was not predictive of overall mortality (p = 0.12). To further investigate this issue, patients with ICH scores of 2 or 3 were separately analyzed to assess the impact of mFI on moderate ICH cases. However, mFI was also not associated with increased hospital mortality in moderate ICH cases (p = 0.812). In bivariate Spearman analysis, mFI significantly correlated with several outcome measures including modified Rankin Scale (MRS) at discharge (p = 0.01), but ICH score also correlated with these outcomes (p < 0.001). Although ICH & mFI scores were both predictive of MRS with linear regression, multivariate demonstrated that the ICH score was the only independent risk factor for MRS (p = 0.698, p < 0.001 respectively). CONCLUSION: Frailty, as measured by the mFI, was not an independent risk factor for increased mortality or worse outcomes in SICH patients. This study does not support incorporating the mFI score for SICH patients for prognostication.

What Does it Mean for a Surgeon to "Run Two Rooms"? A Comprehensive Literature Review of Overlapping and Concurrent Surgery Policies.

The aim of this study was to review and analyze all of the "concurrent surgery" (CS) and "overlapping surgery" (OS) literature with the goal of: standardizing terminology, defining discrepancies in the literature and proposing solutions for the current challenges of regulating surgery to achieve maximal safety and efficiency. The CS and OS literature has grown exponentially over the past two years. Before this, there were no significant publications addressing this topic. There is an extremely wide variance on how "running two rooms" is defined and whether it should be permitted. These differences affect our patients' perception of this practice. The literature lacks any comprehensive review of the topic and terminology. We performed a PubMed search to identify studies that considered the issue of OS. The terms "overlapping surgery", "concurrent surgery", and "simultaneous surgery" (SS) were used in the query. We then analyzed the publications identified. The literature contained 18 published studies analyzing OS safety between November 2016 and June 2018. Eight were neurosurgical studies, three were orthopedic, and the remaining seven articles were in other surgical specialties. A total of 1,207,155 surgical cases (range 250->500,000 patients) were analyzed among the 18 studies. There were 57,880 (5.04%) OS cases. The OS rates in the individual studies ranged from 1.2 to 68 per cent (Table 1). Neurosurgical studies had the highest average OS rate of 54 per cent (range 37-68%), whereas the average OS rate in orthopedic surgery was 43 per cent (range 2.7-68%). Approximately one-third of the studies were multicenter investigations (27.7%). The studies measured more than 20 distinct outcomes, but there were only five outcomes that were included in the majority of the studies: mortality rates, reoperation rates, procedure length of time, readmission rates, and hospital length of stay. The current body of literature repeatedly demonstrates that OS is a safe and effective option when undertaken by experienced surgeons who practice it frequently. For successful OS, the Mandatory Attending Portion for two surgeries must not overlap and Unnecessary Anesthesia Time must be prohibited. Hospitals and surgical specialty organizations must implement policies to assure the safe practice of OS.