The Specialist Treatment of Inpatients: Caring for Diabetes in Surgery (STOIC-D Surgery) Trial: A Randomized Controlled Trial of Early Intervention With an Electronic Specialist-Led Model of Diabetes Care.

OBJECTIVE: To investigate the effect of early intervention with an electronic specialist-led "proactive" model of care on glycemic and clinical outcomes. RESEARCH DESIGN AND METHODS: The Specialist Treatment of Inpatients: Caring for Diabetes in Surgery (STOIC-D Surgery) randomized controlled trial was performed at the Royal Melbourne Hospital. Eligible participants were adults admitted to a surgical ward during the study with either known diabetes or newly detected hyperglycemia (at least one random blood glucose result ≥11.1 mmol/L). Participants were randomized 1:1 to standard diabetes care or the intervention consisting of an early consult by a specialist inpatient diabetes team using electronic tools for patient identification, communication of recommendations, and therapy intensification. The primary outcome was median patient-day mean glucose (PDMG). The key secondary outcome was incidence of health care-associated infection (HAI). RESULTS: Between 12 February 2021 and 17 December 2021, 1,371 admissions met inclusion criteria, with 680 assigned to early intervention and 691 to standard diabetes care. Baseline characteristics were similar between groups. The early intervention group achieved a lower median PDMG of 8.2 mmol/L (interquartile range [IQR] 6.9-10.0 mmol/L) compared with 8.6 mmol/L (IQR 7.2-10.3 mmol/L) in the control group for an estimated difference of -0.3 mmol/L (95% CI -0.4 to -0.2 mmol/L, P < 0.0001). The incidence of HAI was lower in the intervention group (77 [11%] vs. 110 [16%]), for an absolute risk difference of -4.6% (95% CI -8.2 to -1.0, P = 0.016). CONCLUSIONS: In surgical inpatients, early diabetes management intervention with an electronic specialist-led diabetes model of care reduces glucose and HAI.

Sensitivity of Magnetic Resonance Imaging of the Medial Longitudinal Fasciculus in Internuclear Ophthalmoplegia.

BACKGROUND: Internuclear ophthalmoplegia (INO) is a result of insult to the medial longitudinal fasciculus (MLF). Clinicoradiological correlation in patients with INO has been reported to be poor; however, prior studies have used low resolution MRI imaging techniques and included patients with subclinical INO. We aimed to determine the sensitivity of modern MRI interpreted by a specialist neuroradiologist to detect clinically evident INO. METHODS: A retrospective chart review of patients in 2 tertiary University-affiliated neuro-ophthalmology practices with the diagnosis of INO. MRI scans of all patients were reviewed and interpreted by a fellowship-trained neuroradiologist for the presence of lesion in MLF and concordance with the original imaging report. RESULTS: Forty-five patients were included in the study: 33 with demyelinating disease, 11 with stroke, and 1 with intracranial mass. A visible MLF lesion was present in 25/33 demyelinating cases and 7/11 ischemic cases. Lesions in 2 cases in each group were identified only after review by a fellowship-trained neuroradiologist. In demyelinating INO, patients with a visible MLF lesion were more likely to show other brainstem (72%) and supratentorial (51%) white matter lesions. CONCLUSIONS: In 25% of patients with demyelinating INO and 33% of patients with ischemic INO, no visible lesion was identified on current high-quality MRI imaging. Review of imaging by a neuroradiologist increased the possibility of lesion been identified.

Automated insulin delivery among adults with type 1 diabetes for up to 2 years: a real-world, multicentre study.

BACKGROUND AND AIMS: Automated insulin delivery (AID) improves glycaemia among people with type 1 diabetes in clinical trials and overseas real-world studies. Whether improvements are sustained beyond 12 months in the real world, and whether they occur in the Australian context, has not yet been established. We aimed to observe, up to 2 years, the effectiveness of initiating first-generation AID for type 1 diabetes management. METHODS: Retrospective, real-world, observational study using medical records, conducted across five sites in Australia. Adults with type 1 diabetes, who had AID initiated between February 2019 and December 2021, were observed for 6-24 months after initiation (until June 2022). Outcomes examined included glucose metrics assessed by glycated haemoglobin (HbA1c ) and continuous glucose monitoring (CGM), safety and therapy continuation. RESULTS: Ninety-four adults were studied (median age 39 years (interquartile range, IQR: 31-51); pre-initiation HbA1c 7.8% (7.2-8.6)). After AID initiation, HbA1c decreased by mean 0.5 percentage points (95% confidence interval (CI): -0.7 to -0.2) at 3 months (P < 0.001); CGM time in range 3.9-10.0 mmol/L increased by 11 percentage points (9-14) at 1 month (P < 0.001); these improvements were maintained up to 24 months (all P < 0.02). Median CGM time below 3.9 mmol/L was <1.5% pre- and post-AID initiation. The subgroup with pre-initiation HbA1c above 8.5% had the greatest HbA1c improvement (-1.4 percentage points (-1.8 to -1.1) at 3 months). Twelve individuals (13%) discontinued AID, predominantly citing difficulties with CGM. During the 150 person-years observed, four diabetes-related emergencies were documented: three severe hypoglycaemic events and one hyperglycaemic event without ketoacidosis. CONCLUSIONS: Early glucose improvements were observed after real-world AID initiation, sustained up to 2 years, without excess adverse events. The greatest benefits were observed among individuals with highest glycaemia before initiation. Future-generation systems with increased user-friendliness may enhance therapy continuation.

Yield of Investigations in Young Patients Presenting With Transient Monocular Vision Loss: A Prospective Study.

PURPOSE: It is unclear whether transient monocular vision loss (TMVL) warrants the same thorough systemic evaluation for potential embolic sources in young adults as it does in older adults. The objective of the present study was to evaluate the yield of investigations in patients under 45 years of age presenting with TMVL. DESIGN: Prospective cohort study. METHODS: Young adult patients with TMVL presenting to a university-affiliated neuro-ophthalmology clinic were included. All included patients were referred for neuroimaging (computed tomography or magnetic resonance angiography of entire carotid tree and magnetic resonance imaging of the brain) and cardiac investigations (transesophageal echocardiography and 2 weeks of Holter monitoring). RESULTS: A total of 20 participants with TMVL were included in the study. The mean age was 33.1 ± 8.2 years, and 16 of the 20 participants were women. The most common finding on past medical history was migraines, in 5 of 20 cases (25%), and 25% of patients had headaches during their visual loss. Of 17 participants who completed neuroimaging, 1 had fibromuscular dysplasia (this patient also experienced headaches during their symptoms). Two of 13 patients who completed echocardiography had patent foramen ovale. Overall, 3 of 20 participants (15%, 95% CI 3%-38%) had abnormal findings associated with their TMVL. Aspirin treatment was initiated in 2 of 3 patients following investigations. CONCLUSION: In our cohort of young patients presenting with TMVL, 15% of patients had abnormal findings on further investigations. We recommend that young patients presenting with TMVL be referred for neuroimaging and cardiac workup so that appropriate treatments can be initiated to prevent future complications. Headaches during vision loss may not always indicate a benign cause, and retinal migraine should be a diagnosis of exclusion.

Swelling of Atrophic Optic Discs in Idiopathic Intracranial Hypertension.

BACKGROUND: Monitoring patients with idiopathic intracranial hypertension (IIH) and optic atrophy may be difficult as papilledema may not be appreciable on ophthalmoscopy. This retrospective chart review evaluated whether papilledema recurrence can be detected in this population using optical coherence tomography (OCT). METHODS: Serial clinical assessments, ophthalmoscopy, and peripapillary OCT were reviewed in a cohort of patients with IIH and optic atrophy. Atrophy was defined as moderate if average peripapillary retinal nerve fiber layer (pRNFL) thickness was ≤80 µm and severe if average pRNFL thickness was ≤60 µm on at least 2 consecutive high-quality OCT scans. Based on the upper tolerance limit of test-retest variability, mean pRNFL elevation of ≥6 µm with subsequent decrease to baseline thickness was considered papilledema. RESULTS: In a cohort of 165 patients with IIH, 32 eyes of 20 patients and 22 eyes of 12 patients demonstrated moderate and severe optic atrophy, respectively. Over a median follow-up of 198.5 weeks (range, 14.0-428.9), 63.3% (19 of 30) of patients had at least 1 episode of relapse, and 50.0% (15 of 30) had at least 1 episode of papilledema. There was a total of 36 relapse episodes, of which 7 occurred in patients with clinical signs and symptoms but no OCT evidence of relapse, 12 occurred in patients with OCT changes but no clinical signs and symptoms of relapse, and 17 occurred in patients with both clinical and OCT evidence to support relapse. The median percent pRNFL increase in the latter 2 groups was 13.7% (range, 7.5-111.8), and 7 eyes (13.0%) of 5 patients (16.7%) showed thickening greater than 20.0% from baseline. The rate, magnitude, and concordance of pRNFL swelling were similar between moderately vs severely atrophic eyes. CONCLUSIONS: Papilledema recurrence can be detected in atrophic optic discs using OCT. All patients with atrophic IIH should be longitudinally monitored with pRNFL measurement. Concurrence of other relapse-suggestive features should prompt further evaluation.

Maculopathies Referred to Neuro-Ophthalmology Clinic as Optic Neuropathies: A Case Series.

BACKGROUND: The clinical features of maculopathies and optic neuropathies often overlap: Both present with decreased visual acuity and variable loss of color vision; thus, maculopathy can be misdiagnosed as optic neuropathy, leading to patient harm. We aimed to determine what findings and/or tests were most helpful in differentiating between optic neuropathy and maculopathy. METHODS: A retrospective chart review of consecutive patients over 4.5 years who were referred to neuro-ophthalmology clinics with the diagnosis of optic neuropathy but whose final diagnosis was maculopathy. Patient demographics, mode of presentation, clinical profile, complete ophthalmological examination, results of all ancillary testing, and final diagnosis were recorded. RESULTS: A total of 47 patients (27 women) were included. The median age was 55 years (range, 18-85). Most referrals were by ophthalmologists (72.3%) and optometrists (12.8%). The diagnosis of maculopathy was made in 51.1% of patients at the time of first neuro-ophthalmic consultation. Only 6.4% patients (3) had relative afferent pupillary defect. Benign disc anomalies (tilted, myopic, small, or anomalous discs) were present in 34.0%, and 21.3% had pathologic disc changes unrelated or secondary to maculopathy. Macular ocular coherence tomography (OCT) was abnormal in 84.4% (with outer retinal pathology in 42.2% and inner retina pathology in 17.8%). Retinal nerve fiber layer (RNFL) thickness was normal in 82.6% of patients. CONCLUSIONS: Macular OCT is a high-yield test in differentiating between optic neuropathy and maculopathy and should be obtained in patients with suspected optic neuropathies who have normal RNFL thickness. Macular dystrophies, particularly cone dystrophies, unspecified retinal disorders, and macular degeneration were the most common mimics of optic neuropathy. The diagnosis was often present on OCT of the macula. The presence of coexistent benign and pathological disc anomalies may lead to maculopathy being misdiagnosed as optic neuropathy.

Incidence of giant cell arteritis mimicking non-arteritic anterior optic neuropathy.

PURPOSE: Giant cell arteritis (GCA) involving ophthalmic circulation often manifests as anterior ischemic optic neuropathy (AAION), presenting with severe vision loss and pallid optic disc edema. Non-arteritic anterior ischemic optic neuropathy (NAION) classically presents with segmental optic disc edema and corresponding altitudinal visual field defect (VFD) with small cup-to-disc ratio in the fellow eye. Differentiating these two entities is critical as GCA requires immediate treatment to prevent vision loss in the fellow eye. This study investigated how often GCA mimics NAION at presentation. METHODS: Retrospective chart review of patients with temporal artery biopsy (TAB) positive GCA with ocular manifestations seen at a tertiary neuro-ophthalmology practice between 2015 and 2020. Patients presenting with segmental non-pallid optic disc swelling and corresponding altitudinal VFD mimicking NAION were identified. RESULTS: The clinical presentation of 7.1% (3/42) of patients with TAB-positive GCA mimicked NAION. Two of three patients had cup-to-disc ratio of <0.3 in the fellow eye. Two patients were women, mean age was 67.3 ± 6.5 years, and mean presenting visual acuity was 0.45 ± 0.48 LogMAR. Two patients had a normal temporal artery ultrasound. Two of three patients had at least one systemic symptom of GCA at presentation and all had elevation of one or both inflammatory markers. CONCLUSIONS: There should be high index of suspicion for GCA, even in patients highly suspected to have NAION. Inflammatory markers must be checked in every patient with presumed NAION and TAB performed if one or both are elevated to avoid missing GCA.

Continuous Glucose Monitoring-Based Composite Metrics: A Review and Assessment of Performance in Recent-Onset and Long-Duration Type 1 Diabetes.

This study examined correlations between continuous glucose monitoring (CGM)-based composite metrics and standard glucose metrics within CGM data sets from individuals with recent-onset and long-duration type 1 diabetes. First, a literature review and critique of published CGM-based composite metrics was undertaken. Second, composite metric results were calculated for the two CGM data sets and correlations with six standard glucose metrics were examined. Fourteen composite metrics met selection criteria; these metrics focused on overall glycemia (n = 8), glycemic variability (n = 4), and hypoglycemia (n = 2), respectively. Results for the two diabetes cohorts were similar. All eight metrics focusing on overall glycemia strongly correlated with glucose time in range; none strongly correlated with time below range. The eight overall glycemia-focused and two hypoglycemia-focused composite metrics were all sensitive to automated insulin delivery therapeutic intervention. Until a composite metric can adequately capture both achieved target glycemia and hypoglycemia burden, the current two-dimensional CGM assessment approach may offer greatest clinical utility.

Visual Recovery in 2 Cases of Central Retinal Artery Occlusion Treated With Prompt Intra-ophthalmic Artery Fibrinolysis.

BACKGROUND: Central retinal artery occlusion (CRAO) rapidly produces inner retinal ischemia and irreversible vision loss. Although many therapeutic interventions have been proposed, no interventions have proven effective in restoring vision in large randomized controlled trials and final visual outcome in most patients is very poor. METHODS: Retrospective case series. RESULTS: We describe 2 cases of CRAO occurring after uncomplicated cataract surgery under topical anesthesia and rapidly diagnosed. Both had very severe vision loss at presentation with dramatic improvement after intra-ophthalmic artery fibrinolysis administered 2.75 and 5.5 hours after symptom onset. CONCLUSIONS: Sudden monocular vision loss is an ophthalmologic emergency as CRAO must be ruled out and if diagnosed, rapid intervention should be performed. Devastating vision loss can be prevented if interventional neuroradiology is trained and available on a 24-hour basis for administration of local intra-arterial thrombolysis.

Asymptomatic Fellow Eye Involvement in Nonarteritic Anterior Ischemic Optic Neuropathy.

BACKGROUND: Sequential nonarteritic anterior ischemic optic neuropathy (NAION) has been reported to occur in approximately 15% of patients within 5 years of the first episode. However, the incidence of presumed previous asymptomatic episode of NAION in fellow eye of patients presenting with acute NAION has not been previously reported. We reviewed charts of patients with acute NAION seen over a 5-year period to determine the frequency of visual field (VF) defect in the fellow eye secondary to presumed previous asymptomatic episode of NAION. METHODS: Retrospective chart review of all patients presenting to single, tertiary university-affiliated neuro-ophthalmology practice from January 2016 to September 2021 with diagnosis of acute NAION. Patients were determined to have had a presumed previous episode of asymptomatic NAION in the fellow eye if VF defect and corresponding optic nerve head pallor as well as thinning on peripapillary ocular coherence tomography (OCT) and ganglion cell analysis of macular complex were present and alternate causes of VF were excluded. RESULTS: One hundred ninety-two patients with the diagnosis of acute NAION were identified. One hundred thirty-nine had reliable VFs and were included in this study. VF defects in the fellow eye were present in 63 patients (45.4%). Of these, 54 (39%) were determined to represent previous NAION. In 14 of 139 patients (10%), a presumed episode of previous NAION in the fellow eye was asymptomatic. The most prevalent defect in asymptomatic eye was inferior altitudinal defect sparing fixation (7 of 14, 50%). The presence of obstructive sleep apnea, hypertension, diabetes, age, or sex was not predictive of previous episode of asymptomatic NAION. CONCLUSION: Unrecognized presumed previous episode of NAION occurred in a significant proportion of patients with acute NAION (14 of 139, 10.1%). In 100% of cases, the VF defect in the asymptomatic fellow eye was in a hemifield where there was a new loss in the symptomatic eye.

Transsynaptic Ganglion Cell Degeneration in Adult Patients After Occipital Lobe Stroke.

BACKGROUND: Loss of retinal ganglion cells after occipital lobe damage is known to occur through transsynaptic retrograde degeneration in congenital lesions; however, studies of this phenomenon in acquired pathology, such as strokes affecting postgenicular visual pathway, are scant. We studied a cohort of adult patients with known onset of occipital lobe stroke to look for the presence, rate, and timing of macular ganglion cell loss on optical coherence tomography. METHODS: Retrospective review of patients seen in tertiary neuro-ophthalmology practice with homonymous hemianopia secondary to occipital lobe stroke of known onset. Optical coherence tomography of the macular ganglion cell complex (GCC) was performed, and hemifields corresponding to the side of the visual field (VF) defect were compared with the control retinal hemifield. RESULTS: Fifteen patients with homonymous VF defects were included in the study, and 8 of these (53.3%) demonstrated GCC hemifield thickness of less than 90% on the side corresponding to VF loss including 2/9 (22%) patients who had a stroke less than 2.5 years ago and 6/6 (100%) patients who had a stroke longer than 2.5 years ago. The amount of hemifield atrophy correlated to the logarithm of time since stroke onset ( P =0.030) but not age ( P = 0.95) or mean deviation on VF ( P = 0.19). Three patients with longitudinal data showed GCC thinning rates of 1.99, 5.13, and 5.68 µm per year. CONCLUSION: Transsynaptic retrograde degeneration occurs after occipital lobe stroke as early as 5.5 months after injury and was observed in all patients 2.5 years after stroke.

Low probability of myasthenia Gravis in patients presenting to neuro-ophthalmology clinic for evaluation of isolated ptosis.

BACKGROUND: Concerning causes of ptosis, most notably third nerve palsy and Horner's syndrome, can be ruled out with normal ocular motility and pupillary examination. Myasthenia gravis (MG) however, rarely can present with ptosis as an isolated finding. We reviewed all patients presenting to tertiary neuro-ophthalmology practice with ptosis of unknown etiology to determine the frequency of MG. METHODS: Retrospective chart review of patients referred to a tertiary neuro-ophthalmology practice with undifferentiated ptosis. RESULTS: Sixty patients were included in the study. Twenty eight (47%) patients had ptosis along with various abnormalities of ocular motility and/or alignment and 32 (53%) had isolated unilateral ptosis defined as ptosis with absence of diplopia, or symptoms of generalized MG (GMG). Final diagnosis was aponeurotic ptosis due to levator palpebrae dehiscence in the majority (73%) of patients, while 10 (17%) were diagnosed with MG (6 with OMG, 4 with GMG). Diplopia was present in 9/10 patients with MG and 8/10 had abnormal ocular findings on clinical examination such as orbicularis oculi weakness, Cogan's lid twitch or fatiguability of ptosis on sustained upgaze. Only one patient referred for isolated unilateral ptosis was diagnosed with OMG and this patient had orbicularis oculi weakness. CONCLUSIONS: None of the patients with isolated unilateral ptosis and otherwise normal examination had MG. All patients eventually diagnosed with MG had diplopia or orbicularis weakness on examination. Thus, the yield of investigating patients with isolated ptosis for MG is exceedingly low.