IPSILATERAL BULLOUS EXUDATIVE RETINAL DETACHMENT ASSOCIATED WITH EXTRACORPOREAL MEMBRANE OXYGENATION.

PURPOSE: To describe the first known case of an extracorporeal membrane oxygenation (ECMO)-related complication in an adult. METHODS: Case report. RESULTS: A 34-year-old man awaiting a lung transplant for interstitial lung disease was connected to an ECMO circuit as a bridge to lung transplant, with a drainage catheter attached to his right internal jugular vein. Shortly after he was cannulated, he developed blurred vision in his right eye and was found to have a progressively worsening bullous exudative retinal detachment. After receiving a lung transplant and getting decannulated from ECMO, his bullous detachment rapidly improved. The patient's clinical course as well as his ophthalmic testing showed findings inconsistent with alternative diagnoses such as central serous chorioretinopathy. His findings were best explained as a complication of ECMO cannulation. CONCLUSION: Extracorporeal membrane oxygenation may be associated with bullous exudative retinal detachment in rare cases where there is a possible anatomical or physiological predisposition.

MACROANEURYSMS ASSOCIATED WITH CONGENITAL RETINAL MACROVESSELS.

PURPOSE: Congenital retinal macrovessels are large aberrant retinal blood vessels that cross the horizontal raphe and can traverse the central macula. Using multimodal imaging and optical coherence tomography angiography, we describe 2 cases of congenital retinal macrovessel associated with macroaneurysms. METHODS: Two patients presented for evaluation and were found to have congenital retinal macrovessels associated with macroaneurysms. Color photography, optical coherence tomography, fundus autofluorescence fluorescein angiography, and optical coherence tomography angiography were performed and used to establish the diagnosis and monitor resolution at follow-up visits. RESULTS: The first patient presented with central vision loss in the right eye and was noted to have a ruptured macroaneurysm and scattered microaneurysms along the course of a venous macrovessel. After 3 months of observation, the patient's vision improved. The second patient presented for evaluation of a cataract in her left eye and was incidentally found to have an arterial macrovessel in her right eye with an associated macroaneurysm. Both cases demonstrated an intricate capillary network in the central macula best visualized on optical coherence tomography angiography. CONCLUSION: Macroaneurysms can occur on both arterial and venous macrovessels. After rupture of these lesions, hemorrhage and exudation can resolve with observation alone. Macrovessels can also present with microaneurysms. Optical coherence tomography angiography can effectively image the complex capillary network associated with these vascular anomalies.

POSTERIOR SCLERAL MELANOCYTOSIS: A NOVEL FUNDUS FINDING MASQUERADING AS A CHOROIDAL NEVUS.

PURPOSE: To report a case of "posterior scleral melanocytosis," a pigmented lesion of the posterior sclera that clinically resembles a flat choroidal nevus. METHODS: Case report of a patient with posterior scleral melanocytosis. Multimodal imaging, including swept source optical coherence tomography, was used to demonstrate the scleral location of the pigmented lesion and to distinguish its features from a typical choroidal nevus present in the same eye. RESULTS: An 86-year-old woman was seen for regular follow-up for neovascular age-related macular degeneration in her right eye and 2 pigmented lesions in her left eye, both presumed to be choroidal nevi. Anterior segment examination showed no evidence of ocular or dermal melanocytosis. Optical coherence tomography of the pigmented lesion in the left eye showed two distinct patterns. One lesion showed hyperreflectivity within the choroidal tissue associated with posterior shadowing, whereas the second lesion showed normal choroidal reflectivity with hyperreflectivity confined to the inner sclera associated with marked posterior shadowing. CONCLUSION: To the authors' knowledge, this is the first report of posterior scleral melanocytosis, a pigmented fundus lesion confined to the inner sclera. The need for high-penetrance optical coherence tomography to differentiate these lesions from a typical choroidal nevus may explain why this entity has not been previously described. The true nature of this entity will ultimately require histopathologic study.

INNER CHOROIDAL FLOW SIGNAL ATTENUATION IN PACHYCHOROID DISEASE: Optical Coherence Tomography Angiography.

PURPOSE: To study zones of reduced inner choroidal flow signal, foci of reduced inner choroidal thickness, and pathologically dilated Haller layer vessels (pachyvessels) in eyes with pachychoroid disease using optical coherence tomography (OCT) and OCT angiography. METHODS: Patients with treatment-naive pachychoroid disease were recruited. All patients prospectively underwent swept-source OCT and OCT angiography. Zones of reduced choriocapillaris flow were labeled and enumerated. Areas where reduced flow signal was attributable to masking/artifacts were excluded. Regions of inner choroidal thinning were identified on structural OCT and labeled. Overlap between reduced choriocapillaris flow and structural inner choroidal attenuation was quantified using Jaccard indices. The relationship of reduced flow to pachyvessels was recorded. RESULTS: Twenty-four eyes of 19 patients were identified. All eyes exhibited at least one zone of reduced flow. A total of 146 flow signal attenuation zones were identified. Sixty-two (42%) of 146 zones showed overlap or proximity with structural inner choroidal thinning. The mean Jaccard index per eye was 0.10 (SD = 0.08). Pachyvessels were spatially related to 100 (68%) of 146 zones of flow attenuation. CONCLUSION: Zones of reduced choriocapillaris flow are prevalent in eyes with pachychoroid disease. Approximately 60% of these zones anatomically correlate with pachyvessels. Inner choroidal ischemia seems related to the pathogenesis of pachychoroid diseases.

MACULAR PERIVENOUS RETINAL WHITENING AND PRESUMED RETINO-CILIARY SPARING IN A RECURRENT CENTRAL RETINAL VEIN OCCLUSION ASSOCIATED WITH THE ANTIPHOSPHOLIPID SYNDROME AND CRYOGLOBULINEMIA.

PURPOSE: Macular perivenous retinal whitening results from hypoperfusion-induced ischemia of the middle retina that can occur in central retinal vein occlusion (CRVO). We describe an unusual case of recurrent CRVO with macular perivenous retinal whitening and retino-ciliary venous sparing in the setting of 2 prothrombotic diseases, antiphospholipid syndrome and Type II cryoglobulinemia. METHODS: A 50-year-old man presented with intermittent loss of vision in his right eye related to a recurrent CRVO. Color photography, optical coherence tomography, and fluorescein angiography were performed and compared with those obtained during a previous CRVO that occurred 6 years earlier in the same eye. RESULTS: On presentation, visual acuity was hand motion in the right eye, 20/30 in the left eye. Funduscopic examination of the right eye showed vascular tortuosity, scattered retinal hemorrhages, and retinal whitening in the macula. Optical coherence tomography showed hyperreflectivity of the middle layers of the retina that correlated with the areas of retinal whitening. A discrete area of retinal sparing was noted in the superonasal macula that, on fluorescein angiography, corresponded to the distribution of a single retino-ciliary vein. A review of retinal imaging obtained during the patient's previous CRVO showed similar but more subtle findings of retino-ciliary sparing. Laboratory testing revealed antiphospholipid syndrome and Type II cryoglobulinemia. As the patient's CRVO progressed and subsequently stabilized after treatment in the following months, this area of venous sparing remained the only functional, nonischemic retinal tissue in his macula. Presumably, this vein possessed privileged and uncompromised blood flow by circumventing the occluded venous circulation. CONCLUSION: Macular perivenous retinal whitening should be considered in the differential diagnosis of retinal whitening and occurs in CRVO secondary to hypoperfusion-induced middle retinal ischemia. To our knowledge, this case represents the first description of retino-ciliary venous sparing of the retina in CRVO.

PURTSCHER RETINOPATHY AS A MANIFESTATION OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS.

PURPOSE: The authors describe a woman diagnosed with hemophagocytic lymphohistiocytosis and found to have retinal examination findings consistent with Purtscher retinopathy. METHODS: A 52-year-old woman underwent multimodal imaging, including color fundus photography and spectral-domain optical coherence tomography, to confirm the diagnosis. RESULTS: The ophthalmic examination and imaging confirmed the findings of Purtscher retinopathy with significant inner retinal thickening on spectral-domain optical coherence tomography. Throughout a hospital course complicated by multi-organ failure, she continued to have profoundly limited visual acuity, likely resulting from inner retinal ischemia affecting the posterior pole of both eyes. CONCLUSION: The authors describe a patient with hemophagocytic lymphohistiocytosis, a disease characterized by disruption of normal natural killer cell activity with subsequent uncontrolled cytokine release, who presented with Purtscher retinopathy confirmed with spectral-domain optical coherence tomography.

Improvement of severe baseline lower urinary tract symptoms following robotic-assisted laparoscopic prostatectomy.

AIMS: This study was designed to assess lower urinary tract symptoms (LUTS) following robotic-assisted laparoscopic prostatectomy. METHODS: In a single surgeon series, 938 patients underwent robotic prostatectomy and completed International Prostate Symptom Score surveys at baseline and 6-month follow-up. Patients preoperative LUTS were categorized as mild, moderate, or severe according to the original International Prostate Symptom Score validation. Patient demographics, in addition to clinical and pathologic outcomes were obtained from an Institutional Review Board-approved database. RESULTS: Preoperatively, 55.8% of patients presented with mild, 36.4% with moderate, and 7.8% with severe LUTS. Increased prostate size trended with increased LUTS severity (P < 0.001). Patients who had severe preoperative LUTS witnessed a 57% reduction in International Prostate Symptom Score (from 24.1 to 10.7, P < 0.001). Men with moderate preoperative LUTS also witnessed a significant decrease in postoperative LUTS (from 12.1 to 8.3, P < 0.001). CONCLUSIONS: The majority of patients with moderate or severe LUTS improved significantly following robotic prostatectomy, with the largest improvements seen in the severe group. Prostate cancer patients with severe LUTS should be counseled on the beneficial role of robotic prostatectomy in an effort to improve their voiding dysfunction and as a viable cancer treatment.

Clinicopathological, functional, and immediate oncologic outcome assessment in men aged≤50 years with prostate cancer after robotic prostatectomy.

BACKGROUND: To define the pathologic and functional outcomes of men 50 years of age and younger with prostate cancer in a contemporary robotic cohort, this study was designed. METHODS: Patients undergoing robotic-assisted laparoscopic prostatectomy from April 2002 to April 2012 (n = 2,495) formed the base population for the current analyses. The patients were dichotomized according to their age≤50 (n = 271) and>50-year-old (n = 2,224). Clinicopathological and health-related quality-of-life outcomes were recorded and analyzed for differences. Propensity score matching was used when assessing urinary and sexual function outcome. RESULTS: Baseline prostate-specific antigen and clinical stage were similar between men older than 50 years and those younger. Younger patients had less severe disease (D׳Amico risk and Gleason scores) and smaller prostates. Young men had higher rates of erectile function at all time points, including baseline (94% vs. 83% at 12mo, P <0.01). Continence was similar at all time points except for 6 months, where younger patients experienced a faster return than older patients and then remained constant, while older patients continued to improve (96% vs. 89%, P<0.01). After matching process, the difference in erectile function at 6-month follow-up was lost. CONCLUSION: Most men aged 50 years and younger who received robotic-assisted laparoscopic prostatectomy had clinically significant prostate cancer. Although histopathologic and short-term oncologic outcomes were nearly identical when compared to older patients, younger men had a more rapid and superior return of erectile function.

LONG-TERM RETROSPECTIVE ANALYSIS OF VISUAL ACUITY AND OPTICAL COHERENCE TOPOGRAPHIC CHANGES AFTER SINGLE VERSUS DOUBLE PEELING DURING VITRECTOMY FOR MACULAR EPIRETINAL MEMBRANES.

PURPOSE: To determine the long-term effect of internal limiting membrane with associated epiretinal membrane (ERM) peeling versus single peeling alone in terms of best-corrected visual acuity and anatomical outcomes on spectral-domain optical coherence tomography. METHODS: This retrospective comparative cohort study of patients who had follow-up of >1 year and underwent surgery for ERM by a single surgeon (S.C.) from January 1, 2008 to December 31, 2012 compared cases in which the internal limiting membrane was stained with brilliant blue G to facilitate double peeling (n = 42) and single peeling (n = 43) of the ERM alone for up to 3 years of follow-up. For continuous variables, an independent two-tailed t-test was performed. For binary variables, the Fisher's exact test was performed. Statistical significance was defined as P < 0.05. RESULTS: Eighty-five of 142 patients fit the inclusion criteria. At the last follow-up, the single-peeling group were more likely to have ERM remaining in the central fovea postoperatively (P = 0.0020, becoming significant by postoperative Year 1, P = 0.022) and less likely to develop inner retinal dimpling (P = 0.000, becoming significant by postoperative Month 3, P = 0.015). At 3 years, central foveal thickness had decreased in the single-peeling group by -136.9 µm and by -84.1 µm in the double-peeling group, which was not significantly different (P = 0.08). Mean best-corrected visual acuity improved in both the groups at all time points. There was no statistically significant difference between the 2 groups at 3 years (P = 0.44; single-peeling group, 0.32 ± 0.42, Snellen 20/42; double-peeling group, 0.23 ± 0.27, Snellen 20/34). CONCLUSION: Brilliant blue G-assisted internal limiting membrane peeling for ERM results in a more thorough removal of residual ERM around the paracentral fovea. However, there is no difference in long-term best-corrected visual acuity at 3 years and a greater likelihood of inner retinal dimpling.

Long-term follow-up of astrocytic hamartoma of the optic disc associated with gyrate atrophy.

This is a case report of a 15-year-old boy with multiple small peripapillary white growths in the right eye in the setting of gyrate atrophy. Over 3 years of follow-up, these lesions became more clearly delineated as astrocytic hamartomas of the retina and optic disc. In the setting of gyrate atrophy, astrocytic hamartomas are extremely rare. This report represents the second published case and includes characterization of these tumors using spectral-domain optical coherence tomography.

Baseline functional status may predict decisional regret following robotic prostatectomy.

PURPOSE: Physician knowledge of factors related to patient decisional regret following definitive management for localized prostate cancer is an important but under evaluated element in comprehensive patient counseling. Using validated instruments, we analyzed the relationships of pathological, perioperative and functional health related quality of life variables to treatment related regret following robot-assisted laparoscopic prostatectomy. MATERIALS AND METHODS: Of 953 consecutive patients presenting for followup after robot-assisted laparoscopic prostatectomy 703 (74%) completed validated measures of health related quality of life and treatment decisional regret. Baseline functional measures were assessed with the Sexual Health Inventory for Men and International Prostate Symptom Score. Questionnaires were administered a median of 11.1 months (IQR 4.6-26.1) after surgery. Clinicopathological, perioperative and functional outcomes were analyzed with univariable and multivariable models to examine associations with patient decisional regret. RESULTS: Of the patients 88% did not regret the decision to undergo robot-assisted laparoscopic prostatectomy. Baseline health related quality of life, specifically baseline incontinence and superior erectile function, independently predicted increased postoperative decisional regret. In addition, older age, postoperative incontinence measured by pad use, postoperative erectile dysfunction and longer time from surgery were independent predictors of increased decisional regret. Preoperative cancer risk, and histopathological and short-term biochemical outcomes were unrelated to decisional regret. CONCLUSIONS: Decisional regret following robot-assisted laparoscopic prostatectomy is independently predicted by age, baseline urinary and erectile function, perioperative outcomes, and postoperative urinary and erectile function. These results may be useful to urologists during preoperative patient counseling to set realistic expectations for the postoperative course, potentially improving the surgical experience.

Monitoring validated quality of life outcomes after prostatectomy: initial description of novel online questionnaire.

OBJECTIVES: To describe a novel, low-cost, online health-related quality of life (HRQOL) survey that allows for automated follow-up and convenient access for patients in geographically diverse locations. Clinicians and investigators have been encouraged to use validated HRQOL instruments when reporting outcomes after radical prostatectomy. METHODS: The institutional review board approved our protocol and the use of a secure web site (http://www.SurveyMonkey.com) to send patients a collection of validated postprostatectomy HRQOL instruments by electronic mail. To assess compliance with the electronic mail format, a pilot study of cross-sectional surveys was sent to patients who presented for follow-up after robotic-assisted laparoscopic prostatectomy. The response data were transmitted in secure fashion in compliance with the Health Insurance Portability and Accountability Act. RESULTS: After providing written informed consent, 514 patients who presented for follow-up after robotic-assisted laparoscopic prostatectomy from March 2010 to February 2011 were sent the online survey. A total of 293 patients (57%) responded, with an average age of 60 years and a median interval from surgery of 12 months. Of the respondents, 75% completed the survey within 4 days of receiving the electronic mail, with a median completion time of 15 minutes. The total survey administration costs were limited to the web site's $200 annual fee-for-service. CONCLUSIONS: An online survey can be a low-cost, efficient, and confidential modality for assessing validated HRQOL outcomes in patients who undergo treatment of localized prostate cancer. This method could be especially useful for those who cannot return for follow-up because of geographic reasons.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy.

BACKGROUND: We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50-80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses. RESULTS: Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size. CONCLUSION: Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

Retrospective audit of outcome of regional anesthesia for delivery in women with thrombocytopenia.

Regional anesthesia for pain at delivery in the presence of maternal thrombocytopenia is a clinical dilemma. We reviewed 10,369 obstetric cases (12 months) from our tertiary center. Generally, hemodilution of pregnancy does not result in thrombocyte counts of <150,000/mm(3) at delivery. A total of 166 births (1.6%) were recorded in women with thrombocytes <150,000/mm(3) at delivery. Parturients with >150,000/mm(3) at week 36 were separated post hoc (n=35; 21%) and the remaining parturients were divided as having <100,000/mm(3) (n=30; 18%) or 101,000-150,000/mm(3) (n=101; 60.5%). Epidural or spinal anesthesia was administered to 30% women with <100,000/mm(3) whereas 56% women with >101,000/mm(3) received these options (P=0.003). A total of 13.9% of parturients with trimester-long thrombocytopenia required blood products; 10/23 (43.5%) parturients undergoing cesarean section also required blood products (P=0.000). Four of six babies with Apgar scores of