Association between open-angle glaucoma and neovascular age-related macular degeneration: a case-control study.

PurposeTo investigate the relationship between previously diagnosed open-angle glaucoma (OAG) and neovascular age-related macular degeneration (AMD) using a routine insurance dataset.MethodsThis study retrieved data from the Taiwan Longitudinal Health Insurance Database 2005. We found 3282 patients with neovascular AMD as cases and 13 128 sex- and age-matched subjects without neovascular AMD as controls. Conditional logistic regressions were performed to evaluate the association of neovascular AMD with previously diagnosed OAG among the sampled patients.ResultsOf the 16 410 sampled patients, 2.55% had previously diagnosed OAG, 5.06 and 1.92% for the cases and controls, respectively. The logistic regression analysis showed that the odds ratio (OR) of previously diagnosed OAG for cases was 2.45 (OR: 2.45; 95% confidence interval: 1.99-3.01) compared with the controls after adjusting for potential confounders. In addition, the adjusted ORs for previously diagnosed OAG were similar for patients with AMD in both genders (with an adjusted OR of 2.49 for males and 2.39 for females). Furthermore, it shows that OAG was significantly associated with neovascular AMD regardless of sex even after adjusting for monthly income, geographic region, urbanisation level, and comorbidities (with adjusted ORs of 2.49 for males and 2.39 for females).ConclusionsThis study demonstrated that patients with neovascular AMD had a higher odds of previously diagnosed OAG compared with those patients without neovascular AMD regardless of sex.

Neither Basic Life Support knowledge nor self-efficacy are predictive of skills among dental students.

AIM: Basic life support (BLS) is considered a core competence for the graduating dentist. This study aimed to measure BLS knowledge, self-efficacy and skills of undergraduate dental students in Dublin. METHODS: This study consisted of a cross-sectional survey measuring BLS knowledge and self-efficacy, accompanied by a directly observed BLS skills assessment in a subsample of respondents. Data were collected in January 2014. Bivariate correlations between descriptive and outcome variables (knowledge, self-efficacy and skills) were tested using Pearson's chi-square. We included knowledge and self-efficacy as predictor variables, along with other variables showing association, into a binary logistic regression model with BLS skills as the outcome measure. RESULTS: One hundred and thirty-five students participated. Almost all (n = 133, 98.5%) participants had BLS training within the last 2 years. One hundred and four (77%) felt that they were capable of providing effective BLS (self-efficacy), whilst only 46 (34.1%) scored >80% of knowledge items correct. Amongst the skills (n = 85) subsample, 38.8% (n = 33) were found to pass the BLS skills assessment. Controlling for gender, age and skills assessor, the regression model did not identify a predictive relationship between knowledge or self-efficacy and BLS skills. CONCLUSIONS: Neither knowledge nor self-efficacy was predictive of BLS skills. Dental students had low levels of knowledge and skills in BLS. Despite this, their confidence in their ability to perform BLS was high and did not predict actual competence. There is a need for additional hands-on training, focusing on self-efficacy and BLS skills, particularly the use of AED.

Breast nodularity and ulceration: diffuse dermal angiomatosis a corticosteroid responsive disease.

Diffuse dermal angiomatosis of the breast (DDAB) is an uncommon ulcerative angiomatosis, which occurs in middle aged women with large pendulous breasts, a history of cigarette smoking, and risk factors for atherosclerosis. Based on its rarity, no well-defined therapeutic regimen has been elucidated. We report a case of DDAB in a woman with no history of smoking or radiographic evidence of occluded vasculature who presented with ulceration and pain-associated breast nodularity. She had a complete reproducible response to oral corticosteroids.

Dementia is associated with open-angle glaucoma: a population-based study.

PURPOSE: Previous epidemiologic studies that focused on the association between open-angle glaucoma (OAG) and dementia showed inconsistent results. In the present study, we explored the association between OAG and dementia in an ethnic Chinese (i.e., Taiwanese) population using a population-based data set. METHODS: We retrieved data on study subjects for this case-control study from the Longitudinal Health Insurance Database 2000. We identified 7770 patients who had a diagnosis of dementia as cases, and 7770 subjects matched in terms of sex and age, which were randomly extracted as controls. A conditional logistic regression conditioned on age group, sex, and index year was used to assess the association of dementia with previously diagnosed OAG among the sampled patients. RESULTS: Of 15,540 patients, 1.70% had prior OAG, including 2.02% of the dementia group and 1.38% of the controls. After adjusting for patient socioeconomic characteristics and comorbid medical disorders, dementia patients were more likely to have had prior OAG than controls (odds ratio (OR): 1.44; 95% confidence interval (CI): 1.12-1.85; P<0.01). In addition, female dementia patients were more likely to have had prior OAG than controls (OR: 1.93; 95% CI: 1.35-2.77; P<0.001), whereas no statistical difference in prior OAG between male dementia patients and controls was found. CONCLUSIONS: Female dementia patients were associated with a higher proportion of prior OAG than were the controls.

Increased risk of open-angle glaucoma following chronic rhinosinusitis: a population-based matched-cohort study.

PURPOSE: Anatomically, the eyes and paranasal sinuses are neighboring structures and some studies have mentioned eye disease in conjunction with chronic rhinosinusitis (CRS). However, to the best of our knowledge, no prior research has investigated the risk of developing open-angle glaucoma (OAG) among CRS patients. This study aims to provide an estimated risk of developing OAG among patients with CRS by using a population-based data set in Taiwan. METHODS: This retrospective cohort study used data sourced from the 'Longitudinal Health Insurance Database 2000'. A total of 15,642 CRS patients were included in the study cohort and 46,926 subjects were randomly extracted as a comparison cohort. A cox proportional-hazards regression analysis was performed to calculate the 5-year risk of subsequently developing OAG following a diagnosis of CRS between the study cohort and the comparison cohort. RESULTS: The incidence rate of developing OAG over the 5-year follow-up period was 5.45 (95% CI: 4.95-5.98) per 1000 person-years for the study cohort and 2.80 (95% CI: 2.60-3.03) per 1000 person-years for the comparison cohort. After censoring the cases that died over the 5-year period and adjusting for the factors of monthly income, geographic region, hypertension, diabetes, coronary heart disease, hyperlipidemia, and hypothyroidism the hazard ratio for developing OAG over the 5-year period for subjects with CRS to subjects without CRS was 1.73 (95% CI: 1.53-1.96). CONCLUSION: We found that those subjects with CRS had a significantly higher risk of developing OAG over the 5-year follow-up period as compared with subjects without CRS.

Surgeon age and operative outcomes for primary rhegmatogenous retinal detachment: a 3-year nationwide population-based study.

PURPOSE: The aim was to study the association of surgeon age with operative outcomes for primary rhegmatogenous retinal detachment (RRD) in Taiwan. METHODS: A total of 7427 adult patients of primary RRD who were treated by 284 ophthalmologists with scleral buckling (SB), pars plana vitrectomy (PPV), or their combination from 2002 to 2004 were identified in the Taiwan National Health Insurance Research Database. The adjusted odds ratios (OR) of 180-day readmission between ophthalmologist age groups were calculated. RESULTS: For SB, patients treated by ophthalmologists aged >or=51 years had a greater 180-day readmission rate (OR=1.44, 95% confidence interval (CI)=1.01-2.07, P<0.05) than those treated by ophthalmologists aged 41-50 years. For PPV, patients treated by ophthalmologists aged or=51 years (OR=0.58 and 0.22, 95% CI=0.47-0.71 and 0.13-0.63, P<0.001 and <0.001, respectively). For PPV+SB, patients treated by ophthalmologists aged >or=51 years had a higher 180-day readmission rate than those treated by ophthalmologists aged or=51-year groups, respectively. CONCLUSIONS: Surgeon age is a relatively weak predictor for the outcomes of primary RRD surgery in aggregate in Taiwan and certainly not appropriate for discriminating performance among individual surgeons.

Antiglaucoma medications during pregnancy and the risk of low birth weight: a population-based study.

OBJECTIVE: To study the relationship between using antiglaucoma medications during pregnancy and the risk of having low-birth-weight (LBW) infants. METHODS: The study group comprised 244 pregnant women who had been prescribed topical medication to control glaucoma during pregnancy. The comparison group comprised 1952 pregnant women matched for age, year of delivery, maternal hypertension and gestational diabetes. Multivariate logistic regressions were conducted to calculate the adjusted odds ratio of having LBW infants. RESULTS: The majority of pregnant women (77.5%) were prescribed beta-blockers to control glaucoma. After adjusting for characteristics of the infant (gender, parity and gestational age), mother (age, the highest educational level, marital status, hypertension and gestational diabetes), father (the highest educational level), parental age difference and family monthly income, there was no significant difference in the risk of LBW infants between mothers prescribed beta-blockers and mothers in the comparison cohort (adjusted odds ratio (OR) 1.48, 95% CI 0.86 to 2.56). However, there was a significantly higher risk of LBW infants for mothers prescribed topical antiglaucoma medications other than beta-blockers (adjusted OR 2.15, 95% CI 1.05 to 5.00). CONCLUSIONS: Topical beta-blockers can be the first-line drugs when considering medical treatment of glaucoma in a pregnant woman.

Retinal vein occlusion and the risk of acute myocardial infarction (correction of infraction): a 3-year follow-up study.

AIM: Using a nationwide population-based dataset, this study investigated the relationship between retinal vein occlusion (RVO) and subsequent acute myocardial infarction (AMI). METHODS: This study is based on a nationwide database released by the Taiwan National Health Research Institute. The study cohort consisted of all ambulatory care patients who were diagnosed as having RVO during 2000 approximately 2003 (n = 591), while the control cohort comprised 2955 randomly selected patients extracted from the same dataset; five patients for every RVO patient, matched by age and gender. Each patient was individually tracked for 3 years from their index ambulatory care visit. Cox proportional hazard regressions were performed to compute the adjusted 3-year AMI-free survival rates, comparing these two cohorts. RESULTS: RVO patients had a significantly higher rate of AMI (1.86% vs 0.78%) during the 3-year follow-up period than patients in the comparison group (p = 0.032). However, after adjusting for the patients' gender, age, geographic region and comorbid medical disorders, there was no significant difference between the central retinal vein occlusion, branch retinal vein occlusion patients and the comparison group in terms of the hazard of AMI during the 3-year follow-up period. CONCLUSION: RVO did not independently increase the risk of AMI.

Trends and outcomes of treatment for primary rhegmatogenous retinal detachment: a 9-year nationwide population-based study.

PURPOSE: To determine the trends and outcomes for treating primary rhegmatogenous retinal detachment (RRD) in a nationwide population-based study in Taiwan. METHODS: We collected admission data during the period of 1997-2005, from the Taiwan National Health Insurance Research Database, a source that covers over 96% of Taiwan's 23 million citizens. Totally 28 911 patients with a first-time admission diagnosis of RRD (ICD-9-CM codes 361 to 361.07) and undergoing surgical treatment (scleral buckling (SB), pars plana vitrectomy (PPV), or their combination) were identified. The utilized operation type, 180-day readmission rate for recurrent retinal detachment, length of hospital stay, and admission charge were obtained. Contingency table/chi (2) test and t-test were employed for the statistical analysis. RESULTS: Primary PPV (with or without SB) was a primary procedure in 47.3% of cases in 1997. This rate rose significantly to 61.2% in 2005. A significant decrease in the total 180-day readmission rate occurred from 18.95% in 1997 to 13.81% in 2005. These rates also significantly decreased for each surgical modality (from 16.30 to 11.38% for SB, from 21.29 to 14.69% for PPV, and from 22.99 to 16.55% for PPV+SB). The length of hospital stay decreased for each surgical modality between 1997 and 2005. CONCLUSIONS: There was a significant trend towards more frequently employing primary PPV (with or without SB) for the management of primary RRD. In addition, significant improvements in the primary success rates were shown for each surgical modality group and for total samples between 1997 and 2005.

Removal of sodium from the solvent reduces retinal pigment epithelium toxicity caused by indocyanine green: implications for macular hole surgery.

BACKGROUND: s/aims: Staining of internal limiting membrane with indocyanine green (ICG) has been reported to be associated with postoperative atrophic retinal pigment epithelium (RPE) change. Here the authors examined whether removing sodium from the solvent reduces ICG induced RPE cytotoxicity. METHODS: Human RPE cells were exposed to ICG (0.25 and 0.025 mg/ml) reconstituted with balanced salt solution (BSS) or Na(+) free BSS. Light microscopy, trypan blue dye exclusion, acridine orange/ethidium bromide staining, and DNA electrophoresis were used to evaluate the cytotoxic effects of ICG. ICG uptake was measured by optical absorption at 790 nm. RESULTS: Sodium removal reduced the ICG induced changes in cell morphology and improved the RPE cell viability. When RPE cells were incubated for 4 hours in 0.25 mg/ml ICG dissolved in BSS and sodium free BSS, 86.3% (SD 6.7%) and 2.4% (1.1%) of the cells were stained with trypan blue, respectively. After ICG treatment, RPE dies mainly through a necrotic mechanism. ICG uptake by RPE was also reduced with sodium removal. CONCLUSIONS: ICG induced cytotoxicity in cultured human RPE was reduced with removal of sodium from the solvent. This reconstitution method may provide a safer intravitreal use of ICG in macular hole surgery.

Intravitreous tissue plasminogen activator injection and pneumatic displacement in the management of submacular hemorrhage complicating scleral buckling procedures.

PURPOSE: To evaluate the efficacy of recombinant tissue plasminogen activator (rTPA) and sulfur hexafluoride (SF6) in displacing submacular hemorrhage in patients who had scleral buckling procedures complicated by the development of submacular hemorrhage. Final visual acuity and complications of the procedures were evaluated. METHODS: Sequential intravitreal injections of 50 microg rTPA in 0.1 mL and 0.4 cc SF6 were performed in eight patients who showed submacular hemorrhage 1 day after a scleral buckling procedure. The fundus was checked daily for 3 days after the injection of TPA and gas, and then was followed every week for 1 month and then every 2 months. Patients were observed for at least 6 months. Visual acuity and the status of complications were evaluated. RESULTS: Submacular hemorrhage was totally or partially displaced extramacularly in all patients on the day after rTPA and SF6 injection. Vitreous hemorrhage was present in all patients. The retina was attached in all patients and no recurrent retinal detachment was noted. Visual acuity was improved at 6 months after treatment in all seven of the patients with macula-off retinal detachments compared to the preoperative visual acuity. The last patient who had a macula-sparing retinal detachment had decreased vision (20/25) at 6 months compared to preoperatively. CONCLUSIONS: Recombinant tissue plasminogen activator and SF6 injection is an easy procedure that is less complicated than and as effective as internal drainage in patients with submacular hemorrhage developing as a complication of scleral buckling procedures.

Progression of hydroxychloroquine retinopathy after discontinuation of therapy: case report.

Chloroquine and its derivative, hydroxychloroquine sulfate, have been used in treating malaria, dermatitides of systemic lupus erythematosus and rheumatoid arthritis. Hydroxychloroquine retinopathy is uncommon in Taiwan. Here we report a patient with hydroxychloroquine retinopathy which progressed even after discontinuation of hydroxychloroquine. A 42-year-old woman had systemic lupus erythematosus for twenty years. She had been treated with 200 to 400 mg of hydroxychloroquine per day (4 to 8 mg/kg of body weight/day) with a cumulative dose of 657 g. After bull's-eye maculopathy was found, hydroxychloroquine was discontinued. Her medical history revealed no chloroquine administration and no other systemic disease. Five years after cessation of the therapy, her visual acuity and visual fields continued to deteriorate. Ophthalmoscopic examination revealed the hydroxychloroquine retinopathy had advanced. To the best of our knowledge, the progression of hydroxychloroquine retinopathy after discontinuation of medications is a rare phenomenon. Regular ophthalmologic examinations should be performed for patients on hydroxychloroquine regimens because there is no satisfactory treatment for hydroxychloroquine retinal toxicity. Ophthalmologists, dermatologists and rheumatologists should monitor for ocular toxicity of hydroxychloroquine carefully.

Idiopathic polypoidal choroidal vasculopathy: case report.

In 1990, Yannuzzi et al. introduced a new clinical entity, "idiopathic polypoidal choroidal vasculopathy" (IPCV). There is now a more-widespread worldwide recognition of a higher prevalence and importance of this disorder. We report on the first case of IPCV in Taiwan to our knowledge. A 63-year-old Taiwanese man complained of blurred vision in his right eye for 6 months. The anterior segment and vitreous were normal except for mild nuclear cataract changes. Fundus examination of the right eye showed hard exudates and multiple reddish-orange subretinal lesions in the macula. Fundus examination of the left eye was normal. Fluorescein angiography of the right eye showed multiple hyperfluorescent granular lesions in the macula. Subretinal leakage and pooling of fluorescein were present in the temporal macula. Indocyanine green angiography disclosed multiple aneurysmal dilations at the terminals of branching vascular networks. A hyperfluorescent aneurysmal lesion corresponding to the reddish-orange nodule was observed ophthalmoscopically, and a granular lesion was observed in fluorescein angiography. Focal retinal photocoagulation was applied to the leakage area identified with fluorescein angiography. Two months after photocoagulation was performed, the subretinal fluid had gradually resolved, but a new leakage in the macula was demonstrated with fluorescein angiography. His best corrected vision in the right eye was stable.

Bilateral diffuse uveal melanocytic proliferation in a woman with uterine leiomyoma: case report.

Bilateral diffuse uveal melanocytic proliferation (BDUMP) associated with systemic carcinoma is a rare paraneoplastic syndrome. It was reported to be associated with primary carcinomas of the lung, ovary, colon, gall bladder, esophagus, pancreas, uterus, and cervix. We report a case of BDUMP that occurred in a woman with cervical leiomyoma. The 79-year-old woman experienced bilateral progressive visual loss to hand motion within 2 weeks. Fundus examination showed bilateral exudative retinal detachment and multiple oval red patches. Echographic study showed diffuse thickening of the uveal tracts. Fluorescein angiography showed multiple patches of window defect without late leakage, which was correlated with the oval red patches. After screening for tumor markers and meticulous examinations, an elevated serum level of CA-125 was noted. The only neoplasm found in this patient was a cervical leiomyoma, which has never been reported to be associated with BDUMP. One month after the onset of symptoms, accidental head injury due to poor vision led to right parietal intracerebral hemorrhage and left hemiplegia. Prompt diagnosis of this paraneoplastic syndrome is important to discover the underlying malignancy in patients with no history of cancer. For those cases without malignant neoplasm, attention should be directed to the disability caused by the severe visual loss, which led to accidental head injury and intracerebral hemorrhage in this case.

Acute angle-closure glaucoma resulting from spontaneous hemorrhagic retinal detachment in age-related macular degeneration: case reports and literature review.

PURPOSE: Acute angle-closure glaucoma resulting from massive subretinal hemorrhage is a rare and catastrophic complication in age-related macular degeneration. Anticoagulant usage had been strongly correlated with this complication in previously reported cases. METHODS: Four patients (4 eyes), 3 men and 1 woman, developed angle-closure glaucoma with diffuse subretinal hemorrhage and total hemorrhagic retinal detachment. RESULTS: Serial funduscopic examinations and echographic studies in 2 eyes showed that the blood gradually accumulated in the subretinal space. It took more than 10 days for the bleeding to build up to bullous hemorrhagic retinal detachment and secondary glaucoma. Anti-glaucomatous agents were given and sclerotomy was performed in 3 of the 4 patients. Phthisical changes were observed subsequently in these 3 eyes. The eye that received early drainage of blood was an exception, and a small degree of residual acuity was retained. Three of the 4 patients had diabetes mellitus, and hypertension and vascular diseases were also present in the same 3 patients. CONCLUSIONS: Diabetes mellitus might be a predisposing factor for the impaired hemostasis. Anti-glaucomatous agents were of no effect in the management of intraocular pressure. Sclerotomy and drainage of blood help control intraocular pressure and relieve ocular pain. Poor final visual acuity is inevitable. However, phthisical changes might be prevented with early sclerotomy and drainage of blood.

Induction of positive cooperativity by amino acid replacements within the C-terminal domain of Penicillium chrysogenum ATP sulfurylase.

ATP sulfurylase from Penicillium chrysogenum is an allosteric enzyme in which Cys-509 is critical for maintaining the R state. Cys-509 is located in a C-terminal domain that is 42% identical to the conserved core of adenosine 5'-phosphosulfate (adenylylsulfate) (APS) kinase. This domain is believed to provide the binding site for the allosteric effector, 3'-phosphoadenosine 5'-phosphosulfate (PAPS). Replacement of Cys-509 with either Tyr or Ser destabilizes the R state, resulting in an enzyme that is intrinsically cooperative at pH 8 in the absence of PAPS. The kinetics of C509Y resemble those of the wild type enzyme in which Cys-509 has been covalently modified. The kinetics of C509S resemble those of the wild type enzyme in the presence of PAPS. It is likely that the negative charge on the Cys-509 side chain helps to stabilize the R state. Treatment of the enzyme with a low level of trypsin results in cleavage at Lys-527, a residue that lies in a region analogous to a PAPS motif-containing mobile loop of true APS kinase. Both mutant enzymes were cleaved more rapidly than the wild type enzyme, suggesting that movement of the mobile loop occurs during the R to T transition.

Perfluorodecalin condensation on posterior surface of lens capsule and corneal endothelium during vitrectomy.

BACKGROUND: High-density vitreous substitutes, including perfluorodecalin, are widely used in current vitreoretinal surgery. We report 4 cases of perfluorodecalin condensation on the posterior capsule of the lens or corneal endothelium during vitrectomy. To the best of our knowledge, no such phenomenon has ever been reported. METHODS: This study consisted of 4 patients with retinal detachment and large retinal tears. All patients were men. All of the patients underwent pars plana vitrectomy, perfluorodecalin injection, endolaser retinopexy and air-fluid exchange. Two patients received additional surgery for scleral buckling. RESULTS: Perfluorodecalin condensation was observed on the posterior surface of the lens capsule in one phakic patient and on the endothelium in three aphakic patients during vitrectomy. The condensation obscured the image of the fundus and made air-fluid exchange difficult. The condensation could be dissipated by first removing the perfluorodecalin as completely as possible, and then by lowering the intraocular pressure below the vapor pressure of perfluorodecalin. CONCLUSIONS: Perfluorodecalin condensation may occur when perfluorodecalin is not properly used. To avoid forming condensation, high-density vitreous substitutes should never be injected into eyes that are completely air-filled, prolonged air-fluid exchanges should be avoided, and the intraocular pressure should always be kept at a higher level during air-fluid exchange.

Prehospital consideration of sildenafil-nitrate interactions.

OBJECTIVE: To determine whether paramedics and on-line physicians screen patients for use of sildenafil citrate (Viagra) prior to prehospital administration of nitrates. METHODS: A prospective, observational study was performed over a one-month period in three EMS systems. Consecutive radio communications between on-line physicians and paramedics concerning male patients with cardiac complaints were monitored. Investigators observed the frequency with which on-line physicians screened for sildenafil use prior to ordering nitrates. After observation of the radio communications was completed, a written survey was distributed to all paramedics in the three EMS systems. RESULTS: Seventy-six physician-paramedic interactions were monitored. Nitrates were ordered by on-line physicians in 56 cases. No paramedic reported sildenafil use/nonuse, and no on-line physician inquired about the patient's potential use of the drug. Only half of the surveyed paramedics reported that they routinely screen for sildenafil use, and approximately a fourth reported that its use would not alter their management of chest pain patients. CONCLUSION: In this study, on-line physicians in three EMS settings did not screen for sildenafil use prior to ordering nitrates. While some paramedics do screen for sildenafil use, practice patterns among paramedics in these three systems were inconsistent.