EXTENSIVE ORBITAL AND PARAPHARYNGEAL EMPHYSEMA REQUIRING URGENT CANTHOTOMY AND CANTHOLYSIS AFTER PARS PLANA VITRECTOMY.

PURPOSE: The authors report the emergent management of a case of orbital and parapharyngeal emphysema causing orbital compartment syndrome and signs of peripheral neuropathy days after pars plana vitrectomy. METHODS: Case report. RESULTS: A 20-year-old woman underwent 3-port 23-gauge pars plana vitrectomy in the right eye for total retinal detachment under general anesthesia. All sclerotomies were secured with 7-0 polyglactin 910 (Vicryl; Ethicon) sutures before instillation of 15% C3F8 gas. On the third postoperative day, the patient presented with a 3-mm proptosis, near-total ophthalmoplegia, jaw protrusion, head deviation, tongue protrusion, and facial twitching. Computed tomography showed extensive subcutaneous gas in the right orbit and bilateral parapharyngeal spaces, and a tethered right optic nerve with globe tenting. A decision was made to perform urgent lateral canthotomy and cantholysis. Three hours after canthotomy and cantholysis, her neurologic signs had resolved except for intermittent tongue protrusion, which resolved thereafter. At postoperative Week 7, the patient's vision was 20/70 and her intraocular pressure was 13 mmHg. CONCLUSION: To the authors' knowledge, this is the only report of a modern small-gauge vitrectomy procedure being complicated by orbital compartment syndrome and extensive emphysema causing peripheral neuropathy, and successfully treated with urgent canthotomy and cantholysis.

Significance of subconjunctival hemorrhage in predicting ocular pathology for patients with orbital fracture.

OBJECTIVE: Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture. DESIGN: Retrospective chart review. PARTICIPANTS: Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018. METHODS: Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI. RESULTS: Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ2 analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%). CONCLUSIONS: Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma.

Evaluating newer generation intraocular lens calculation formulas in manual versus femtosecond laser-assisted cataract surgery.

AIM: To determine the refractive accuracy of the Haigis, Barrett Universal II (Barrett), and Hill-radial basis function 2.0 (Hill-RBF) intraocular lens (IOL) power calculations formulas in eyes undergoing manual cataract surgery (MCS) and refractive femtosecond laser-assisted cataract surgery (ReLACS). METHODS: This was a REB-approved, retrospective interventional comparative case series of 158 eyes of 158 patients who had preoperative biometry completed using the IOL Master 700 and underwent implantation of a Tecnis IOL following uncomplicated cataract surgery using either MCS or ReLACS. Target spherical equivalence (SE) was predicted using the Haigis, Barrett, and Hill-RBF formulas. An older generation formula (Hoffer Q) was included in the analysis. Mean refractive error (ME) was calculated one month postoperatively. The lens factors of all formulas were retrospectively optimized to set the ME to 0 for each formula across all eyes. The median absolute errors (MedAE) and the proportion of eyes achieving an absolute error (AE) within 0.5 diopters (D) were compared between the two formulas among MCS and ReLACS eyes, respectively. RESULTS: Of the 158 eyes studied, 64 eyes underwent MCS and 94 eyes underwent ReLACS. Among MCS eyes, the MedAE did not differ between the formulas (P=0.59), however among ReLACS eyes, Barrett and Hill-RBF were more accurate (P=0.001). Barrett and Hill-RBF were both more likely to yield AE<0.5 D among both groups (P<0.001). CONCLUSION: The Barrett and Hill-RBF formula lead to greater refractive accuracy and likelihood of refractive success when compare to Haigis in eyes undergoing ReLACS.

Gonioscopy-Assisted Transluminal Trabeculotomy in Younger to Middle-Aged Adults: One-Year Outcomes.

PURPOSE: To assess the 1-year surgical outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in young to middle-aged patients. DESIGN: Retrospective case series. PARTICIPANTS: Eyes of patients between 18 and 64 years of age who underwent GATT, with and without concomitant cataract surgery, at 2 academic centers in Montreal, Canada. METHODS: Success was defined as intraocular pressure (IOP) between 6 and 21 mmHg (criterion A) or between 6 and 18 mmHg (criterion B) and a relative IOP reduction of 20% or more compared with baseline. Failure consisted of not meeting the success criteria at 2 or more consecutive visits after the first postoperative month, reoperation because of uncontrolled IOP or disease progression, or loss of light perception. Predictors of success and postoperative changes in outcome measures, including IOP and medication use, were assessed. Intraoperative and postoperative adverse events were noted. MAIN OUTCOME MEASURES: Success, IOP, and medication reduction at the 1-year follow-up and baseline predictors of surgical success. RESULTS: Fifty-six eyes with a mean age of 46.94 ± 11.81 years and preoperative IOP of 27.70 ± 10.30 mmHg taking 3.73 ± 0.98 glaucoma medications were included. At 1 year, IOP decreased from 27.70 ± 10.30 mmHg before surgery to 14.04 ± 3.75 mmHg (49% reduction; P < 0.001) and medication use decreased from 3.73 ± 0.98 medications before surgery to 1.82 ± 1.47 (51% reduction; P < 0.001). The 12-month success was 84% (according to both criteria), and younger age at diagnosis of glaucoma (18-39 years) was predictive of surgical success. The most common postoperative adverse events included transient hyphema, IOP spikes, and transient microcystic corneal edema. CONCLUSIONS: A paucity of evidence exists regarding the efficacy of GATT in young to middle-aged adults. Our results highlight that this surgical procedure has good 1-year outcomes with an acceptable safety profile, supported by the significant IOP and medication reduction observed after surgery. With younger age at diagnosis of glaucoma being a predictor of surgical success, the pathophysiologic features of open-angle glaucoma in younger patients may be more localized to the trabecular meshwork, therefore making GATT a particularly suitable procedure for these patients.

Analysis of Funding Source and Spin in the Reporting of Studies of Intravitreal Corticosteroid Therapy for Diabetic Macular Edema: A Systematic Review.

PURPOSE: This systematic review examined the relationship between industry funding and the presence of spin in high-impact studies evaluating intravitreal corticosteroid therapy for diabetic macular edema. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE and Embase were systematically searched from inception through July 16, 2018, for randomized controlled trials and meta-analyses investigating the treatment of patients with diabetic macular edema using intravitreal corticosteroid therapy. Only studies published in English journals with an impact factor greater than 2 as per the Clarivate Analytics 2017 Journal Citation Report were included. The authors independently assessed study quality, funding source and the presence of reporting bias using a standardized datasheet. RESULTS: Title and abstract screening were completed on 7158 unique hits and full-text review yielded 44 included studies. Overall, there was correspondence between the wording of abstract conclusions and study results in 41/44 (93%) articles. Correspondence between abstract conclusions and significance of main outcome was present in 14/14 (100%) industry-funded and 27/30 (90%) nonindustry-funded studies. The odds ratio of industry funding being associated with noncorrespondence was 0.27 (95% CI: 0.01-5.61, p=0.54). The most common reason for noncorrespondence was the failure to mention rates of steroid-related intraocular pressure elevation. CONCLUSION: The results of this systematic review indicate that biased abstract outcome reporting is rare in published randomized controlled trials and meta-analyses of intravitreal corticosteroid therapy for diabetic macular edema. Biased reporting was not associated with the presence of industry funding or a conflict of interest.

Applying rigorous eligibility criteria to studies evaluating prognostic utility of serum biomarkers in pulmonary embolism: A systematic review and meta-analysis.

PURPOSE: To evaluate the value of biomarkers to prognosticate outcomes in patients with pulmonary embolism among studies of sound methodical quality. METHODS: Ovid MEDLINE, Embase, CENTRAL, and non-indexed citations were searched from inception to March 2019. Biomarkers of interest included troponin I (TnI), troponin T (TnT), high-sensitive TnT (HS-TnT), brain natriuretic peptide (BNP), N-terminal pro-BNP (NT-proBNP), heart fatty acid binding protein (H-FABP), and D-dimer (DD). Included studies utilized key features of the Reporting Recommendations for Tumour Marker Prognostic Studies (REMARK) checklist and satisfied requirements of the Quality in Prognosis Studies (QUIPS) tool. The primary outcome was 30-day all-cause mortality (ACM). Secondary outcomes included PE-related mortality, or complicated clinical course (CCC). Pooled relative risk ratios (RR) were calculated using inverse-variance-weighted random-effects method. RESULTS: Seventeen studies were analyzed. TnT ≥ 0.1 ng/mL and HS-TnT ≥ 14 pg/mL were associated with an increased 30-day ACM with RRs of 6.24 (95% CI, 1.86-20.96, I2 = 35%) and 6.81 (95% CI, 2.46-18.88, I2 = 0%), respectively. In the short-term (≤30 days): (1) TnI can prognosticate PE-related mortality; (2) both TnT and HS-TnT can prognosticate a CCC; (3) H-FABP can prognosticate a CCC; and (4) NT-proBNP can prognosticate a CCC. In the long-term (>30 days): (1) HS-TnT can prognosticate ACM; and (2) NT-proBNP can prognosticate ACM and PE-related mortality. CONCLUSIONS: Several methodically sound studies allow for data pooling, and suggest that TnT, HS-TnT, TnI, NT-proBNP and H-FABP have prognostic value in patients with PE but confidence intervals are wide and relatively few patients constitute the analyses. The value of such markers on influencing clinical management remains to be determined. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019129889.

Outcomes of Rhegmatogenous Retinal Detachment Repair With Nonrestricted Postoperative Positioning.

Purpose: To investigate the anatomical success rate associated with rhegmatogenous retinal detachment (RRD) repair without postoperative head positioning. Methods: Data on 182 individuals undergoing pars plana vitrectomy (PPV) with or without phacoemulsification or scleral buckle for primary RRD with intraocular tamponade were retrospectively reviewed. The primary outcome was the initial anatomical success rate. Secondary outcome measures were the change in best-corrected visual acuity and the final reattachment rate. Results: A total of 122 eyes from 122 patients who underwent RRD repair without postoperative positioning were included in this study. PPV alone was performed in 39% of cases, whereas the remaining patients had PPV combined with phacoemulsification (35%), with scleral buckle (19%), or both (7%). Inferior breaks between the 4 o'clock and 8 o'clock positions were present in 47% of cases. Primary and final anatomical success was achieved in 86% and 98% of cases, respectively. The most common cause for redetachment was proliferative vitreoretinopathy. Age and combined inferior retinal and superior breaks were predictive of recurrence in the logistic regression model. The mean baseline best-corrected visual acuity improved from 1.2 (Snellen equivalent, 20/320) to 0.76 (Snellen, 20/125) logarithm of the minimum angle of resolution after retinal reattachment (P < .001). Conclusions: PPV combined with or without phacoemulsification or scleral buckle for primary RRD in pseudophakic eyes or those rendered pseudophakic is associated with good anatomical outcomes without restricted postoperative head positioning. Retinal detachment in eyes with combined retinal inferior and superior breaks may have a lower success rate, and whether this is due to lack of postoperative positioning needs further evaluation in prospective, controlled studies.

Reduced social participation among seniors with self-reported visual impairment and glaucoma.

OBJECTIVE: Social participation benefits health. We assessed the relationship between self-reported visual impairment (VI) and glaucoma versus seniors' social participation. METHODS: Data from individuals aged ≥65 years responding to the Canadian Community Health Survey Healthy Aging 2008/2009 (n = 16,369) was analyzed. Participation in eight social activities by seniors with and without self-reported VI or glaucoma was compared. RESULTS: Seniors with VI had significantly reduced participation (p<0.05) in sports/physical activities (18.0% vs. 33.6%), family/friendship activities outside the household (39.7% vs. 53.0%), service club/fraternal organization activities (11.4% vs. 18.4%), volunteer/charity work (13.4% vs. 24.9%), educational/cultural activities (16.2% vs. 24.5%), and other social recreational activities (21.6% vs. 31.0%) compared to those without VI. Differences in participation in church/religious activities (40.6% vs. 44.5%) and community/professional association activities (15.3% vs. 18.0%) were non-significant between seniors with and without VI. Seniors with glaucoma versus those without had significantly reduced participation (p<0.05) in family/friendship activities (46.6% vs. 52.9%), sports/physical activities (26.0% vs. 33.6%) and volunteer/charity work (20.4% vs. 24.9%). No participation in any social activity was significantly higher among seniors with VI versus those without (10.1% vs. 2.9%, p<0.05), but was similar among seniors with and without glaucoma (3.9% vs. 3.1%, p>0.05). After adjusting for the effects of age, sex, education, household income, ethnicity, job status and chronic diseases (adjusted odds ratio, aOR = 3.4 (95% confidence interval (CI) 2.0-5.8), seniors with VI but no glaucoma were more likely not to engage in any social activities compared to seniors without VI and no glaucoma. Seniors with glaucoma but without VI had a similar level of non-participation (aOR = 0.9, 95%% CI 0.5-1.7). CONCLUSIONS: Significantly reduced social participation was found across six community activities among seniors with self-reported VI and in three activities among those with self-reported glaucoma. Policies and programs that help seniors with VI or glaucoma engage in social activities are needed.

Refractive Laser-Assisted Cataract Surgery versus Conventional Manual Surgery: Comparing Efficacy and Safety in 3144 Eyes.

PURPOSE: To report on outcomes of the efficacy and safety in 1 of the largest series of eyes undergoing either conventional manual cataract surgery (MCS) or refractive femtosecond laser-assisted cataract surgery (ReLACS). DESIGN: Retrospective, consecutive, interventional comparative case series. METHODS: This study included 3144 consecutive eyes, of which 1580 were treated via MCS, and 1564 were treated via ReLACS at Uptown Surgical Centre in Vaughan, Ontario, Canada. Preoperative characteristics, best corrected visual acuity (BCVA), mean absolute spherical error (MAE), rates of intraoperative posterior capsular rupture, and postoperative complications were evaluated. RESULTS: Across all eyes, ReLACS was superior to MCS for reducing surgical time (MCS: 7.7 ± 0.1 min vs ReLACS: 6.8 ± 0.1 min, P < 0.001); was less commonly associated with postoperative cystoid macular edema (OR = 0.36, 95% CI: 0.14-0.91, P = 0.031) and more commonly reduced MAE (MCS: 0.60 ± 0.02 diopters (D) vs ReLACS: 0.54 ± 0.02 D, P = 0.02). There were no differences in rates of posterior capsular rupture (P = 0.918), overall postoperative complications (P = 0.088) or final BCVA (P = 0.881). When analyzing a subgroup of more difficult cases (n = 833), ReLACS was superior to MCS for: 1) being more likely to yield an improvement of more than 0.1 logarithm of the minimum angle of resolution BCVA (OR = 1.80, 95% CI: 1.15-2.74, P = 0.01); 2) reducing MAE (MCS: 0.73 ± 0.3 D vs ReLACS: 0.60 ± 0.27 D, P = 0.04); and 3) being more likely to yield an MAE within 0.5 D (OR = 1.61, 95% CI: 1.11-2.33, P = 0.012). CONCLUSIONS: Across all eyes, our results support that ReLACS and MCS yield similar outcomes. However, our results show trends toward a more pronounced benefit of ReLACS compared to MCS when treating more difficult eyes.

Determining the hospital cost of anterior epistaxis treatment modalities at a Canadian tertiary care centre.

OBJECTIVE: To estimate the hospital costs of managing anterior epistaxis in the Emergency Department at a Tertiary Care centre in Canada. MATERIAL AND METHODS: A cost analysis was conducted based on a retrospective review of Emergency Department visits from January 2012 to May 2014. A consecutive sample of adult patients with a diagnosis of anterior epistaxis was included. Anterior epistaxis was managed via one of: Nasal clip, Merocel®, Silver Nitrate cautery, Vaseline packing, other treatment or no treatment. Both the direct and indirect hospital costs ($CDN) for anterior epistaxis treatment were calculated from the hospital's perspective. Generalized linear models were used to assess the association between treatment modalities and total hospital costs while controlling for potential confounding factors. RESULTS: Three hundred and fifty-three patients (49% female) with a mean age of (69.9 ± 18.5) years were included in the analysis. The median (interquartile ranges) costs of treatment ranged from C$227.83 (C$167.96, C$328.69) for observation to C$763.98 (C$632.25,C$830.23) for Merocel®. The overall median total hospital costs incurred across all modalities was C$566.24 (C$459.61, C$753.46) for the management of anterior epistaxis. Silver Nitrate, nasal clip, and observation were statistically associated with a lower cost when compared to Merocel® (P < 0.001) even after potential confounding factors were controlled. CONCLUSIONS: Our results show wide difference in the hospital cost of epistaxis across treatment modalities. These cost estimates can help inform future economic evaluation studies aiming to guide the allocation of health care resources for patients with epistaxis.

Malignant Gastric Outlet Obstruction from Pancreatic Cancer.

Patients with advanced-stage pancreatic cancer are typically burdened by many symptoms that impair functioning and worsen quality of life. We report an exceptional case of a 73-year-old woman with T4N1M0 adenocarcinoma of the uncinate process of the pancreas who developed significant gastric outlet obstruction - an uncommon yet potentially life-threatening complication of disease progression. She developed progressive abdominal pain and emesis, and profound dilatation of her stomach was detected on a radiation therapy simulation CT scan that required urgent decompression. Malignant gastric outlet obstruction must be included in the differential diagnosis when patients with known advanced disease of the pancreas present with obstructive upper gastrointestinal symptoms.