The Importance of Health Literacy in Addressing Eye Health and Eye Care Disparities.

Disparities in eye health and eye care frequently result from a lack of understanding of ocular diseases and limited use of ophthalmic health services by various populations. The purpose of this article is to describe the principle of health literacy and its central role in enhancing health, and how its absence can result in poorer health outcomes. The article evaluates the current status of health literacy in visual health and disparities that exist among populations. It also explores ways to improve health literacy as a means of reducing disparities in visual health and eye care. Advancing dissemination of health information and enhancing health literacy may help not only to reduce healthcare barriers in the underserved populations but also to lessen visual health disparities.

Squamoid Eccrine Ductal Carcinoma of the Eyelid: Clinicopathologic Correlation of a Case.

Squamoid eccrine ductal carcinoma (SEDC) is a rare cutaneous neoplasm that often manifests as a plaque or nodule in sun-exposed areas of older patients. Herein, the authors report the first case of SEDC in the eyelid. A 76-year-old man presented with a 2.5 × 1.5 mm area of left upper eyelid erythema, thickening, ulceration, and scaling with madarosis superotemporally just above the lash line. Full-thickness wedge biopsy demonstrated irregular epithelial tubules with nuclear atypia and focal squamous differentiation, consistent with SEDC. The patient underwent Mohs resection and has had no recurrence approximately 27 months after surgical removal. The authors present this case to raise awareness of SEDC to ophthalmologists as all previous cases have been described in the nonophthalmic literature. A full-thickness biopsy is recommended to avoid misdiagnosing SEDC as squamous cell carcinoma (SCC), a less aggressive tumor. With greater awareness, there may be increased recognition of this likely underreported, more malignant entity.

Lateral Tarsal Strip Complications With and Without Conjunctiva Stripping.

PURPOSE: The lateral tarsal strip (LTS) procedure is commonly used to correct eyelid malposition. When performing LTS, some surgeons elect to remove conjunctiva from the tarsal strip, while others do not. It has been hypothesized that without conjunctival stripping, the buried conjunctival tissue can cause complications such as inclusion cysts and granulomas. However, there is limited data comparing LTS cases with and without conjunctiva removal. The authors sought to evaluate whether conjunctival stripping had any impact on complication rates with LTS. METHODS: LTS operations for ectropion correction were retrospectively reviewed and were separated into 2 cohorts, Con (conjunctiva not removed) or Coff (conjunctival removed). Charts were reviewed for outcomes and complications including inclusion cyst formation, granuloma formation, wound dehiscence, infection, and focal rim tenderness. RESULTS: The complication rate was 10% versus 8% for Con versus Coff respectively ( p = 0.54). The common complications of LTS surgery were granuloma (4%), wound dehiscence (3%), focal rim tenderness (3%), and infection requiring antibiotics (<1%). There was no significant difference in these complications between the Con and Coff cohorts. CONCLUSIONS: Complications in both groups were minimal, similar to prior studies, and there was no difference between the 2 cohorts. While it has been suggested that buried conjunctiva may result in increased complication rates, the author's findings suggest that removing the tarsal conjunctiva is a superfluous step in the LTS surgery and does not affect complication rates.

Thyroid eye disease with choroidal folds.

Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED).Methods: A multi-center retrospective case series of patients with TED who developed CRF.Results: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF (p = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF.Conclusions: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.

Vaso-occlusive Infarction of the Lateral Orbital Wall With Ipsilateral Temporalis Muscle Ischemia.

An 18-month-old boy with sickle cell disease developed progressive left periorbital edema and temporalis fullness. Imaging revealed two inferotemporal subperiosteal fluid collections and adjacent temporalis muscle thickening. After undergoing an anterior orbitotomy with drainage and biopsy, the patient was diagnosed as having a vaso-occlusive sickle cell crisis involving the lateral orbit. [J Pediatr Ophthalmol Strabismus. 2020;57:e78-e81.].

Evaluating the Effectiveness of Small-Group Training in Teaching Medical Students Integral Clinical Eye Examination Skills.

OBJECTIVE: The aim of this study is to evaluate the effectiveness of an interactive, small-group ophthalmology clinical training session by assessing medical students' self-confidence with eye examination skills and long-term retention of direct ophthalmoscopy skills. METHODS: The second-year medical students participated in a one-time small-group clinical training session that taught essential components of the eye examination. Students reported their confidence with each component in pre- and postsession surveys. Eight months later, direct ophthalmoscopy skills were reassessed by having students visualize the optic nerves of standardized patients and identify the matching optic nerve photograph in a multiple-choice quiz. RESULTS: Among 197 second-year medical students who participated in the training session, 172 students completed the presession survey (87.3% response rate) and 108 students completed the postsession survey (54.8% response rate). Following the training session, students reported increased self-confidence (p < 0.01) overall. A total of 107 (107/108; 99.1%) students reported that they visualized the optic nerve head, and 80 out of 85 (94.1%) students stated that they preferred the PanOptic ophthalmoscope over the traditional direct ophthalmoscope. Students reported greater self-confidence using the PanOptic ophthalmoscope (p < 0.01). In the 8-month follow-up assessment, 42 medical students (42/197; 21.3%) completed the exercise. A total of 41 (41/42; 97.6%) students stated that they saw the optic nerve with the PanOptic ophthalmoscope; 24 (24/42; 57.1%) students identified the correct optic nerve image using the PanOptic ophthalmoscope on a standardized patient; 14 (14/42; 33.3%) students stated that they saw the optic nerve with the traditional direct ophthalmoscope; and 4 (4/42; 9.1%) students from the same cohort identified the correct optic nerve image with the traditional direct ophthalmoscope on a standardized patient. CONCLUSION: Our comprehensive, one-time eye examination skills training session seeks to prepare students to incorporate these skills in future patient care. Students' overall confidence improved in each aspect of the eye examination that was covered. A follow-up assessment on students' direct ophthalmoscopy skills suggests that the PanOptic ophthalmoscope allows for superior skills retention as compared with the traditional direct ophthalmoscope. We believe that the PanOptic ophthalmoscope should be further integrated into medical education and clinical practice.

Etiologies of Proptosis: A review.

Proptosis, the protrusion of the eyeball from the orbit, results from a wide variety of pathologies that can be vision- or life-threatening. Clinical history, associated physical exam findings, and imaging features are all crucial in establishing the underlying etiology. The differential diagnosis is broad, and includes infectious, inflammatory, vascular, and neoplastic entities that range from benign and indolent, to malignant and aggressive. While treatment varies significantly based on the disease process, all are aimed at preserving vision, salvaging the globe, preventing disfigurement, and reducing mortality. Both internists and general ophthalmologists should be familiar with the causes of proptosis in order to initiate the work-up for, and appropriately triage, affected patients.

Microcornea, posterior megalolenticonus, persistent fetal vasculature, chorioretinal coloboma (MPPC) syndrome: Case series post vitrectomy.

PURPOSE: MPPC syndrome has been described as a syndrome that presents with chorioretinal coloboma, posterior megalolenticonus, persistent fetal vasculature, and chorioretinal coloboma. The purpose of our study is to report three patients who present with a variation of MPPC syndrome who each underwent pars plana vitrectomy, pars plana lensectomy, and amblyopic management. Clinical characteristics, ancillary test findings, and post-surgical functional results are compared to what is reported in the literature. METHODS: Retrospective review of medical records of patients who presented with microcornea, persistent fetal vasculature, chorioretinal coloboma, and microphthalmia who underwent surgical correction at Bascom Palmer Eye Institute. RESULTS: 3 patients (6 eyes) were included, two males and one female. All patients were born full term, vaginally, and had no family history of genetic abnormalities affecting the eye. All patients had color fundus images, fluorescein angiography (FA) and echography. Four eyes underwent surgery. Following surgical intervention, patients demonstrated improved visual acuity, and improved functional status. CONCLUSION AND IMPORTANCE: Patients with microcornea, PFV, chorioretinal coloboma, and microphthalmos, can benefit from surgical intervention when functional decline or media opacities are noted. Though difficult to assess accurate visual acuity and visual improvement pre-operatively and post-operatively, it is evident that our patients demonstrated improvement in functionality and vision following surgical intervention.

Bioengineered dermal substitutes for the management of traumatic periocular tissue loss.

PURPOSE: Traumatic periocular injuries occasionally result in significant soft tissue loss, for which there are limited management options that provide satisfactory cosmetic and functional outcomes. The authors describe the use of a bioengineered dermal substitute (Integra® Dermal Regeneration Template [DRT], Integra LifeSciences, Plainsboro, NJ) as an alternative to immediate flap reconstruction or skin grafting. METHODS: Retrospective interventional case series of patients who underwent DRT placement for periocular tissue loss at the time of trauma. In each case, primary closure or immediate flap reconstruction was deemed impractical or undesirable due to the size and location of the primary and associated secondary defects. One to four weeks later, the outer silicone layer was removed and healing assessed. Additional reconstructive techniques were performed as needed. RESULTS: Three patients were treated at Bascom Palmer Eye Institute and one at Byers Eye Institute at Stanford. The defects healed completely in two patients, and by 79.2% in a third, with no need for additional reconstructive surgery. In the remaining patient, the defect was significantly downsized by 56.1%, allowing for a simpler flap reconstruction. CONCLUSIONS: Bioengineered dermal substitutes should be considered as a viable alternative to traditional reconstructive techniques for large periocular defects resulting from trauma. The outer silicone layer prevents desiccation and serves as a protective barrier, while the inner collagen matrix organizes the growth of neo-dermis and minimizes wound contraction. The dimensions of cutaneous defects can therefore be reduced dramatically, potentially eliminating the need for skin grafting and/or reducing the ultimate complexity of flap reconstruction.

Gene Expression Profiling and Heterogeneity of Nonspecific Orbital Inflammation Affecting the Lacrimal Gland.

Importance: Although a variety of well-characterized diseases, such as sarcoidosis and granulomatosis with polyangiitis, affect the lacrimal gland, many patients with dacryoadenitis are diagnosed as having nonspecific orbital inflammation (NSOI) on the basis of histology and systemic disease evaluation. The ability to further classify the disease in these patients should facilitate selection of effective therapies. Objective: To test the a priori hypothesis that gene expression profiles would complement clinical and histopathologic evaluations in identifying well-characterized diseases and in subdividing NSOI into clinically relevant groups. Design, Setting, and Participants: In this cohort study, gene expression levels in biopsy specimens of inflamed and control lacrimal glands were measured with microarrays. Stained sections of the same biopsy specimens were used for evaluation of histopathology. Tissue samples of patients were obtained from oculoplastic surgeons at 7 international centers representing 4 countries (United States, Saudi Arabia, Canada, and Taiwan). Gene expression analysis was done at Oregon Health & Science University. Participants were 48 patients, including 3 with granulomatosis with polyangiitis, 28 with NSOI, 7 with sarcoidosis, 4 with thyroid eye disease, and 6 healthy controls. The study dates were March 2012 to April 2017. Main Outcomes and Measures: The primary outcome was subdivision of biopsy specimens based on gene expression of a published list of approximately 40 differentially expressed transcripts in blood, lacrimal gland, and orbital adipose tissue from patients with sarcoidosis. Stained sections were evaluated for inflammation (none, mild, moderate, or marked), granulomas, nodules, or fibrosis by 2 independent ocular pathologists masked to the clinical diagnosis. Results: Among 48 patients (mean [SD] age, 41.6 [19.0] years; 32 [67%] female), the mclust algorithm segregated the biopsy specimens into 4 subsets, with the differences illustrated by a heat map and multidimensional scaling plots. Most of the sarcoidosis biopsy specimens were in subset 1, which had the highest granuloma score. Three NSOI biopsy specimens in subset 1 had no apparent granulomas. Thirty-two percent (9 of 28) of the NSOI biopsy specimens could not be distinguished from biopsy specimens of healthy controls in subset 4, while other examples of NSOI tended to group with gene expression resembling granulomatosis with polyangiitis or thyroid eye disease. The 4 subsets could also be partially differentiated by their fibrosis, granulomas, and inflammation pathology scores but not their lymphoid nodule scores. Conclusions and Relevance: Gene expression profiling discloses clear heterogeneity among patients with lacrimal inflammatory disease. Comparison of the expression profiles suggests that a subset of patients with nonspecific dacryoadenitis might have a limited form of sarcoidosis, while other patients with NSOI cannot be distinguished from healthy controls.

Split face evaluation of long-pulsed non-ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars.

PURPOSE: To investigate 1,064 nm long-pulse Nd:YAG laser for postoperative treatment of direct browplasty scars. METHODS: Nine patients who underwent direct browplasty were enrolled in this prospective study. Subjects were randomized to unilateral laser treatment at 2-week intervals for six total treatments, with the contralateral scar used as a control. Prior to each treatment, subjects rated treated and control scars on overall cosmesis. Post-treatment, subjects rated each for erythema, swelling, discomfort, and perceived hair loss. Finally, examiners masked to treatment side were asked to judge side-by-side photographs of first and final visits for improvement and side effects. RESULTS: Subjects rated the overall appearance of the treated scar significantly higher at the time of treatment number 5 (mean score 5.13 ± 2.03, P = 0.008) and treatment number 6 (6.25 ± 1.98, P = 0.005) compared to treatment 1 (3.75 ± 2.12); by contrast, they failed to rate the control scar more highly. On masked examination of photographs, the treated scar was selected as most improved 50.0 ± 12.5% of the time. Both subjects and graders reported side effects as transient and mild to moderate (mean score 1-4), with no reports of hair loss from either subjects or observers. CONCLUSIONS: The 1,064 nm Nd:YAG laser provided significant improvement in scar cosmesis after direct browplasty, as rated by subject self-report, but not by masked observers, and appears to be a useful tool for increasing satisfaction among those dissatisfied with direct browplasty scars. Side effects-including erythema, edema, and discomfort-were transient and universally rated as mild to moderate. Lasers Surg. Med. 48:742-747, 2016. © 2016 Wiley Periodicals, Inc.

Impact of Eyelid Laxity on Symptoms and Signs of Dry Eye Disease.

PURPOSE: To study the relationship between eyelid laxity and ocular symptoms and signs of dry eye (DE). METHODS: A total of 138 patients with normal external anatomy were prospectively recruited from a Veterans Administration hospital. Symptoms (via the Dry Eye Questionnaire 5 and Ocular Surface Disease Index) and signs of DE were assessed along with presence or absence of eyelid laxity. RESULTS: It was observed that 71% of participants (n = 98) had clinical evidence of eyelid laxity (upper and/or lower) compared with 29% (n = 40) with no eyelid laxity. Individuals with eyelid laxity were older (67 ± 10 vs. 55 ± 8 years without laxity, P < 0.005) and more frequently male (76% of males had laxity vs. 18% females, P < 0.005). Patients with eyelid laxity had increased symptoms and signs of DE compared with their counterparts without laxity including ocular pain described as grittiness (63% vs. 45%, P = 0.049), decreased tear break-up time (8.6 ± 3 vs. 10.3 ± 4 seconds, P = 0.02), increased corneal staining (2.5 ± 3 vs. 1 ± 2, P = 0.002), decreased Schirmer score (14±6 vs. 17±7 mm, P = 0.01), increased meibomian gland drop out (2 ± 1 vs. 0.8 ± 0.8, P < 0.005), increased eyelid vascularity (0.8 ± 0.8 vs. 0.2 ± 0.5, P < 0.005), and more abnormal meibum quality (2 ± 1.3 vs. 1.4 ± 1.2, P = 0.02). In a multivariable analysis considering both signs of DE and laxity, lower eyelid laxity remained significantly associated with ocular surface disease index scores, suggesting a direct effect of laxity on symptoms of DE. CONCLUSIONS: The presence of eyelid laxity associates with abnormal tear parameters compared with the absence of eyelid laxity. Based on these data, it is important for clinicians to test for eyelid laxity in patients with symptoms and/or signs of DE.

Recurrent Dermatofibrosarcoma Protuberans Masquerading as a Lacrimal Sac Neoplasm: A Case Report and Review.

A 71-year-old African American man presented with an indolent growth above the left medial canthus. CT of the orbits revealed a circumscribed, homogeneously enhancing 2.1 × 2.2 × 2.5 cm mass that appeared to extend into the medial orbit and proximal nasolacrimal duct without obstructing it. Intraoperatively, the mass was readily dissected free and excised in toto. Histopathology demonstrated spindle cells in a storiform pattern. Immunohistochemical staining was consistent with dermatofibrosarcoma protuberans (DFSP) although the t(17;22) translocation was absent. The patient underwent two-thirds of the recommended intensity-modulated radiation therapy dose before refusing further treatment. He declined additional interventions in favor of serial imaging. He remained recurrence free at 11 months. To the best of the authors' knowledge, this is the first case of recurrent DFSP invading the orbit managed with conservative resection and adjuvant therapy. A comprehensive review of the literature pertaining to DFSP of the orbit is presented.

Purtscher-Like Retinopathy and Diffuse Alveolar Hemorrhage Caused by Soft Tissue Injection for Gluteal Augmentation.

PURPOSE: To describe a rare occurrence of acute vision loss and diffuse alveolar hemorrhage following a treatment of injectable gluteal cosmetic filler. PATIENT AND METHODS: A 20-year-old female underwent a cosmetic injection of unknown components for gluteal augmentation. Within hours she developed progressive shortness of breath secondary to diffuse alveolar hemorrhage. She presented to ophthalmology 6 weeks later with a history of bilateral decreased vision. Clinical examination revealed cotton wool spots and retinal hemorrhages. Fluorescein angiography demonstrated macular vascular pruning and an enlarged foveal avascular zone. RESULTS: The patient was observed and vision did not improve after 8 months of follow-up. CONCLUSION: These findings were attributed to a Purtscher-like retinopathy secondary to systemic inflammation induced by the filler and/or direct microembolization of the injected material or fat. To the best of the authors' knowledge, this is the first documented case of diffuse alveolar hemorrhage and ischemic bilateral vision loss in a patient undergoing gluteal augmentation with dermal filler.

En bloc resection of lacrimal sac tumors and simultaneous orbital reconstruction: surgical and functional outcomes.

PURPOSE: To describe a surgical technique of en bloc resection of lacrimal sac tumors by the shared expertise of 2 specialists to achieve optimal tumor margin clearance and the simultaneous reconstruction of the bony defect to preserve ocular functions and cosmesis. METHODS: All patients who had resection of malignant nasolacrimal drainage system tumors using the combined technique and posttreatment protocol between 1997 and 2011 were studied in this retrospective, noncomparative, interventional case series. A combined medial maxillectomy and medial orbitotomy for en bloc resection of the lacrimal sac tumor was followed by reconstruction with a tailored contoured titanium mesh to support the globe and eyelid. Disease relapse, disease survival, ocular functions (vision loss, motility, globe dystopia, and diplopia), and cosmesis (medial canthal tendon dystopia and eyelid retraction) were documented. RESULTS: Fourteen patients with malignant lacrimal sac tumors underwent en bloc resection. Postoperative radiation was ultimately administered to 9 patients. All patients but one were alive at last follow up. Tumor recurred locally in 2 patients with a regional recurrence in a third patient. Complications from radiation therapy included skin breakdown over the mesh (9/14 patients) with nasocutaneous fistula, medial canthal tendon dystopia (2/14 patients), and corneal perforation in a patient with recurrent disease. Despite removal of the tear drainage system, only 7 of 14 patients reported epiphora. None of the patients developed diplopia after resection and radiation therapy. CONCLUSIONS: The combined sinus-orbit approach is an effective method of managing lacrimal sac tumors to achieve optimal tumor clearance from the orbit and nasal cavity. Simultaneous reconstruction of the bony defect with a contoured titanium mesh provides a fixation anchor for the medial canthal tendon and globe support and serves as a supporting platform for the lower eyelid and cheek to minimize midface collapse. Postoperative radiation is associated with skin flap breakdown and nasocutaneous fistula formation.

An anatomically based approach to intralesional corticosteroid injection for eyelid capillary hemangiomas.

BACKGROUND AND OBJECTIVE: To describe a corticosteroid injection technique for eyelid capillary hemangiomas that minimizes the risk of a central retinal artery occlusion and is based on anatomic, physiologic, and pharmacologic rationales. PATIENTS AND METHODS: In this retrospective, non-comparative, interventional case series, the medical records of 50 eyes of 50 patients over a 10-year period were reviewed for retinal complications associated with the described injection technique. RESULTS: Ophthalmoscopy showed no retinal complications in the 50 eyes treated with this injection technique. CONCLUSION: The risk of central retinal artery occlusion from retrograde embolization can be minimized by using an anatomically based injection technique that prevents canalization of an artery and avoids injection pressures exceeding the mean systemic arterial pressure.

Antimicrobial resistance profiles of ocular and nasal flora in patients undergoing intravitreal injections.

PURPOSE: To identify the resistance profiles of conjunctival and nasal bacterial isolates in patients undergoing intravitreal injections and to determine if frequent exposures to topical fluoroquinolones increased antimicrobial resistance among these organisms. DESIGN: Prospective cohort study. METHODS: Patients undergoing intravitreal injection at our institution were enrolled in this study. The conjunctiva and nares of both sides of the patient's face were swabbed and cultured before antiseptic preparation for intravitreal injection. At the time of the study, all patients received 3 days of moxifloxacin eye drops after each intravitreal injection as prophylaxis against endophthalmitis. Resistance to antimicrobials was analyzed using the chi-square test and t test. RESULTS: Two hundred eight conjunctival and nasal specimens were cultured from 104 patients. Forty-two (45%) of 93 patients had at least 1 fluoroquinolone-resistant organism in the nose or conjunctiva. Twelve (48%) of 25 patients with no previous injections had at least 1 resistant organism; 14 (45%) of 31 patients with 1 to 4 previous injections had at least 1 resistant organism; 8 (33%) of 24 patients with 5 to 9 previous injections had at least 1 resistant organism; and 8 (62%) of 13 patients with 10 or more previous injections had at least 1 resistant organism (P = .88; chi-square test, linear by linear association). CONCLUSIONS: In this small study, there was no correlation between the number of exposures to topical fluoroquinolones and resistance to fluoroquinolones in nasal and conjunctival flora, but there was a high prevalence of fluoroquinolone resistance among all patient groups.

Ocular Toxocariasis in a Seronegative Adult.

Ocular nematodal infections typically affect children. This article demonstrates the utility of enzyme-linked immunosorbent assay (ELISA) testing of the aqueous humor and vitreous to aid the diagnosis of ocular toxocariasis in adults. A 62-year-old woman presented with a 2-year history of worsening vision in her left eye. Examination of the fundus revealed tractional membranes over the optic nerve and nasal retina. Serologic evaluation was unrevealing. The patient was referred to the Bascom Palmer Eye Institute for an anterior chamber ELISA, which was positive for Toxocara. A vitrectomy and scleral buckling procedure was performed. The patient achieved anatomic success after surgery, but her visual acuity in the left eye remained hand motions. This case highlights the importance and utility of ELISA testing of the anterior chamber fluid and/or vitreous aspirate for ocular toxocarasis. This patient is among the oldest described to have active ocular toxocariasis.

Left ventricular lead electrical delay predicts response to cardiac resynchronization therapy.

BACKGROUND: Intracardiac electrograms can be used to guide left ventricular (LV) lead placement during implantation of cardiac resynchronization therapy (CRT) devices. Although attempts often are made to ensure that the LV lead is positioned at a site of maximal electrical delay, information on whether this is useful in predicting the acute hemodynamic response and long-term clinical outcome to CRT is limited. OBJECTIVES: The purpose of this study was to assess the ability of intracardiac (electrogram) measurements made during LV lead placement in patients undergoing CRT for predicting acute hemodynamic response and long-term clinical outcome to CRT. METHODS: Seventy-one subjects with standard indications for CRT underwent electrogram measurements and echocardiograms performed in the acute phase of this study. The LV lead electrical delay was measured intraoperatively from the onset of the surface ECG QRS complex to the onset of the sensed electrogram on the LV lead, as a percentage of the baseline QRS interval. Echocardiographic assessment of the hemodynamic response to CRT was measured as an intra-individual percentage change in dP/dt over baseline (DeltadP/dt, derived from the mitral regurgitation Doppler profile) with CRT on and off. dP/dt was measurable in 48 subjects, and acute responders to CRT were defined as those with DeltadP/dt >or=25%. Long-term response was measured as a combined endpoint of hospitalization for heart failure and/or all cause mortality at 12 months. Time to the primary endpoint was estimated by the Kaplan-Meier method, with comparisons made using the log rank test. RESULTS: LV lead electrical delay correlated weakly with DeltadP/dt of the combined group (n = 48, r = 0.311, P = .029) but was strongly correlated with DeltadP/dt in the nonischemic subgroup (n = 20, r = 0.48, P = .027). LV lead electrical delay (%) was significantly longer in acute responders (69.6 +/- 23.9 vs 31.95 +/- 11.57, P = .002) among patients with nonischemic cardiomyopathy. A reduced LV lead electrical delay (<50% of the QRS duration) was associated with worse clinical outcome within the entire cohort (hazard ratio: 2.7, 95% confidence interval: 1.17-6.68, P = .032) as well as when stratified into ischemic and nonischemic subgroups. CONCLUSION: Measuring LV lead electrical delay is useful during CRT device implantation because it may help predict hemodynamic response and long-term clinical outcome.