Glaucoma Medication and Quality of Life after Phacoemulsification Combined with a Xen Gel Stent.

Glaucoma has a significant impact on quality of life. Here, we aimed to evaluate the influence of a reduction in glaucoma medications on quality of life and patient satisfaction after phacoemulsification combined with the Xen gel stent. We carried out a cross-sectional survey of patients who underwent phacoemulsification with the Xen gel stent at the Medical University of Graz, Austria. Quality of life was assessed using the German version of the Glaucoma Symptoms Scale (GSS)-questionnaire. Patients were also asked whether the operation reduced glaucoma medications and to indicate their overall satisfaction from 1 (totally discontented) up to 10 (totally contented). Questionnaires of 80 patients were evaluated. A total of 36 patients (45.0%) reported a reduction in glaucoma medications. Three items of the GSS were significantly better in patients who needed fewer glaucoma medications after the operation ("hard to see in daylight", 75.0 ± 31.1 vs. 57.7 ± 39.1, p = 0.035; "hard to see in dark places", 81.1 ± 28.7 vs. 54.9 ± 41.2, p = 0.002; and "halos around lights", 88.3 ± 25.9 vs. 68.8 ± 38.6, p = 0.002). Patient satisfaction was significantly higher when the procedure led to a reduction in glaucoma medication (8.3 ± 2.0 vs. 6.8 ± 3.1; p = 0.034). The reported quality of life and patient satisfaction were significantly better when phacoemulsification with the Xen gel stent reduced the number of glaucoma medications needed.

Effects of Type 2 Diabetes Mellitus and Smoking on Changes in Corneal Endothelial Morphology and Cell Density.

PURPOSE: The purpose of this study was to compare the corneal endothelial morphology and cell density of diabetic smokers and nonsmokers with 50 to 70 age-matched healthy subjects and to determine whether smoking increases the effects of type 2 diabetes mellitus (DM) on these corneal parameters. METHODS: This prospective cohort study included 200 patients who were assigned to 4 groups, including smokers with type 2 DM (group 1), nonsmokers with type 2 DM (group 2), healthy smokers (group 3), and healthy nonsmokers (control group, group 4). Noncontact specular microscopy was used to measure central endothelial cell density (ECD), coefficient of variation of cell area, percentage of hexagonal cells, and central corneal pachymetry (CCT). RESULTS: According to the ECD and CCT values ( P < 0.001 and P = 0.013, respectively), a significant difference was observed between the groups. The mean ECD was lowest in diabetic smokers (1917 ± 399 cells/mm 2 ). Healthy smokers and diabetic smokers had significantly lower ECD compared with the control group ( P = 0.03 and P < 0.001, respectively). Healthy smokers and diabetic smokers had significantly lower ECD compared with diabetic nonsmokers ( P = 0.012 and P < 0.001, respectively). The cornea was significantly thicker in the diabetic smokers than in the control group ( P = 0.013). CONCLUSIONS: The coexistence of DM and smoking causes a significant decrease in ECD and an increase in CCT. Cigarette smoking is more harmful to corneal endothelial cells than DM alone.

Automatic detection of pupil reactions in cataract surgery videos.

In the light of an increased use of premium intraocular lenses (IOL), such as EDOF IOLs, multifocal IOLs or toric IOLs even minor intraoperative complications such as decentrations or an IOL tilt, will hamper the visual performance of these IOLs. Thus, the post-operative analysis of cataract surgeries to detect even minor intraoperative deviations that might explain a lack of a post-operative success becomes more and more important. Up-to-now surgical videos are evaluated by just looking at a very limited number of intraoperative data sets, or as done in studies evaluating the pupil changes that occur during surgeries, in a small number intraoperative picture only. A continuous measurement of pupil changes over the whole surgery, that would achieve clinically more relevant data, has not yet been described. Therefore, the automatic retrieval of such events may be a great support for a post-operative analysis. This would be especially true if large data files could be evaluated automatically. In this work, we automatically detect pupil reactions in cataract surgery videos. We employ a Mask R-CNN architecture as a segmentation algorithm to segment the pupil and iris with pixel-based accuracy and then track their sizes across the entire video. We can detect pupil reactions with a harmonic mean (H) of Recall, Precision, and Ground Truth Coverage Rate (GTCR) of 60.9% and average prediction length (PL) of 18.93 seconds. However, we consider the best configuration for practical use the one with the H value of 59.4% and PL of 10.2 seconds, which is much shorter. We further investigate the generalization ability of this method on a slightly different dataset without retraining the model. In this evaluation, we achieve the H value of 49.3% with the PL of 18.15 seconds.

Choroidal Infiltration as First Clinical Manifestation of T-cell Large Granular Lymphocyte (T-LGL) Leukemia.

Purpose: To report of a 55-year-old woman suffering from choroidal infiltrates as a first clinical manifestation of T-LGL leukemia. Methods: Retrospective case report. Results: A healthy woman presented with photophobia in both eyes since 1 month. She showed a panuveitis with anterior chamber as well as vitreous cells, creamy-white choroidal lesions in both eyes and a cystoid macular edema in the left eye. Lab testing showed only a moderate lymphocytosis, all other tests, including a pars plana vitrectomy and an anterior chamber tap, were negative. Due to the persistent lymphocytosis, she was referred to the oncologist. A biopsy of the bone marrow revealed T-LGL leukemia. A subsequent biopsy of the choroid showed an infiltration of T-LGL and therefore systemic therapy with cyclophosphamide was started. Conclusions: This is a very rare case describing an involvement of the choroid in T-LGL leukemia.

Ocular toxicity due to Trametinib and Dabrafenib.

BACKGROUND: To report a case of uveitis and neuroretinal detachment in a patient treated with Trametinib and Dabrafenib due to metastatic cutaneous melanoma stage IV. CASE PRESENTATION: We evaluated slit lamp examination, fundoscopy, optical coherence tomography, fluorescein and indocyanine green angiography in a 66 years old man suffering visual loss. Fundoscopy showed serous neuroretinal detachment of the fovea accompanied with white spots surrounding the fovea in both eyes. Although therapy with Trametinib and Dabrafenib was stopped uveitis anterior was seen 2 weeks later. After a year, the therapy was started again and the serous neuroretinal detachment appeared once more, however without inflammatory reaction of the anterior chamber. CONCLUSION: Patients treated with Trametinib and Dabrafenib should undergo consecutive eye examinations from the beginning of the therapy.

What lessons can be learned from the Austrian events?

INTRODUCTION: The death of 5 children in Austria below the age of 6 years due to posttonsillectomy haemorrhage in 2006 and 2007 led to an intensive discussion on the potential life-threatening risks of tonsil surgery. On this occasion, a consensus paper with clear recommendations for tonsil surgery was released by the Austrian Societies of Otorhinolaryngology, Head and Neck Surgery and Paediatrics followed by a nationwide multicentre study. METHODS: All consecutive tonsillectomies, tonsillotomies and adenoidectomies performed in public hospitals in Austria within 9 months were assessed. Data on all participating patients were collected via an online questionnaire requesting patient characteristics, surgery details and postoperative haemorrhage. A strict definition for postoperative bleeding episodes with 7 severity grades was applied. Every bleeding episode after extubation was counted as postoperative bleeding event. RESULTS: The study population - all younger than 18 years of age - consisted of 6,765 patients (tonsillectomy 2,080, 31%; tonsillotomy 1,292, 19%; adenoidectomy 3,393, 50%). Postoperative haemorrhage episodes were reported in 15% after tonsillectomy and in 2.3% after tonsillotomy, with the risk increasing parallel to age. Multiple bleeding episodes were recorded in one fourth of all tonsillectomy bleedings, but were rare after tonsillotomy. Surgical revision under general anaesthesia was necessary in 4.2% after tonsillectomy and in 0.9% after tonsillotomy. DISCUSSION: As the incidence of tonsillectomy in children younger than 6 years has declined following the recommendations of the consensus paper issued in 2007, tonsillotomy has become more frequent in this age group. Overnight hospital admission and observation is suggested for all patients experiencing postoperative haemorrhage, as the occurrence of one minor bleeding doubled the risk of a second severe bleeding.

Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations.

The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.

Significant post-tonsillectomy pain is associated with increased risk of hemorrhage.

OBJECTIVES: In this study, we set out to assess the association of postoperative pain types with the risk of hemorrhage after tonsillectomy. METHODS: The questionnaire-based study was conducted on 335 patients who had undergone tonsillectomy. Hemorrhage risk and postoperative pain were evaluated retrospectively with use of a visual analog scale for 5 time periods (day 1, days 2 to 3, days 4 to 7, days 7 to 14, and later). RESULTS: Five pain types were identified by a cluster analysis. The most frequent pain types, I (24.8%; 83 patients) and II (50.8%; 170 patients), show decreasing pain, with pain type II starting on a higher level than pain type I. Pain types III (10.7%; 36 patients) and IV (1.2%; 4 patients) start at a low level with increasing pain for the first few days. In type III, pain decreases after 1 week, whereas type IV consists of a high level of pain for more than 2 weeks. Pain type V (12.5%; 42 patients) involves a very high level of pain from the beginning, which decreases only gradually. Pain type I is associated with a low hemorrhage rate. Patients with increasing pain (types III and IV) and pain type V show a significantly higher hemorrhage risk. CONCLUSIONS: Patients who have severe or increasing pain in the first few days after tonsillectomy have a significantly higher risk of hemorrhage.

Hemorrhage following tonsil surgery: a multicenter prospective study.

OBJECTIVES/HYPOTHESIS: Postoperative hemorrhage as a serious complication after tonsillectomy (TE), tonsillotomy (TO), or adenoidectomy (AE) is covered in many studies, using rather inconsistent measurement methods. We introduce a new classification for the severity of postoperative hemorrhage and investigate risk factors for the frequency and severity of bleeding episodes. STUDY DESIGN: Prospective, multicenter cohort study. METHODS: Our study is based on a prospective census recording all TEs, TOs, and AEs from October 1, 2009, to June 30, 2010, in Austria. Information concerning surgery indication, grade of surgeon, operation technique, and postoperative hemorrhage, classified as any bleeding episode after extubation according to severity, were collected. RESULTS: A total of 9,405 patients were included. Hemorrhage rate for TE ± AE was 15.0%, for TO ± AE was 2.3%, and for AE was 0.8%. Rate of return to the operating room for TE ± AE was 4.6%, for TO ± AE was 0.9%, and for AE was 0.3%. Minor bleeding episodes increased the risk of a subsequent severe bleeding episode (P < .001). Elevated hemorrhage rates were observed for adults (P < .001), TE ± AE (P < .001), and cold steel dissection combined with bipolar diathermy (P = .05). Multivariate logistic regression model for the frequency of post-TE hemorrhage showed significant odds ratios for males, children aged <6 years, children aged 6-15 years, abscess TE, and cold steel combined with bipolar diathermy. In addition, we found a significantly higher risk of severe bleeding episodes for children aged 6-15 years (P = .007), males (P = .02), and all bipolar operation techniques (P = .005). CONCLUSIONS: The occurrence of a postoperative minor bleeding episode increases the risk of a subsequent severe bleeding episode.

Tonsilar haemorrhage and re-admission: a questionnaire based study.

The aim of our study was to investigate the accuracy of haemorrhage rate in the community (i.e., actual rate versus hospital recorded rate) for tonsil operations. Bleeding episodes were investigated for 695 consecutive patients undergoing tonsillectomy, adenotonsillectomy and tonsillotomy at the Department of ORL, H&NS, MU of Graz, Austria, between January 1 2007 and June 30 2008 by questionnaire. Main purposes of our study were the evaluation of the incidence of postoperative haemorrhage, need for revision surgery, medical care of patients experiencing postoperative bleeding and multiple bleeding episodes. Haemorrhage was defined as any bleeding, be it minimal or significant, after extubation. The study group comprised 407 patients who answered the questionnaire: 61.7% adults, 22.1% school children between 6 and 15 years and 16.2% children aged less than 6 years. Exactly 100 patients (24.6% of 407) showed some kind of postoperative bleeding, but only 79 of them (19.4% of 407) were recorded at hospital. A return to theatre due to haemorrhage was required in 4.7% of all 407 cases. Combining hospital records and data from the questionnaire allowed us to estimate an overall haemorrhage rate of 21.4% for all 695 patients. Every fifth patient experiencing postoperative haemorrhage did not return to the hospital he or she was operated in. We would have missed 21.0% of all bleeding episodes by assessing re-admitting patients suffering postoperative bleeding only. We conclude that haemorrhage rate is considerably higher than assumed by investigating hospital records only and strongly related to the definition of postoperative bleeding and to the study design.