State-level desegregation in the U.S. South and mid-life cognitive function among Black and White adults.

RATIONALE: Black adults experience worse cognitive function than their White peers. Although educational attainment is an important predictor of cognitive function, other aspects of education, including school desegregation, may also shape this relationship. For Black adults who grew up in the U.S. South in the 1950s-1970s, exposure to school desegregation may have altered life course pathways critical for later cognitive function. OBJECTIVE: We determined if state variation in exposure to school desegregation in the U.S. South was associated with cognitive function at mid-life, if the association varied by race, and if the association remained after adjustment for state-level education quality and respondents' educational attainment. METHODS: We linked historical data on state-level school desegregation to the Health and Retirement Study, a nationally representative sample of U.S. adults aged 50 and older. We restricted our sample to Black (n = 1443) and White (n = 1507) adults born between 1948 and 1963 who resided in the U.S. South during primary school. We assessed three cognition outcomes: total cognitive function, episodic memory, and mental status. We estimated race-stratified linear regression models with cluster adjustment and a final model using state fixed effects. RESULTS: Greater exposure to desegregated primary schooling was associated with higher cognitive function and episodic memory among Black but not White adults. Among Black adults, the association between school desegregation and cognitive function and episodic memory remained after adjustment for state-level education quality and educational attainment. CONCLUSIONS: Our findings suggest that state-level school desegregation efforts played a consequential role in shaping the cognitive function of Black adults who grew up in the U.S. South.

The Association between Foveal Floor Measurements and Macular Hole Size.

PURPOSE: Determining which factors influence idiopathic macular hole (MH) size is important because it is a major prognostic indicator of treatment success. Foveal pit morphologic features are highly symmetrical within individuals and may influence idiopathic MH size. Using a series of patients with unilateral idiopathic MHs, we examined the foveal floor size of the fellow eye to evaluate its relationship with idiopathic MH size and postoperative outcomes. DESIGN: Retrospective observational study. PARTICIPANTS: Two hundred forty-one participants with a unilateral idiopathic MH treated with surgery and a fellow eye with no ocular pathologic features. METHODS: Both eyes underwent spectral-domain (SD) OCT imaging at the time of surgery. Minimum linear diameter (MLD) and base diameter (BD) defined idiopathic MH size. Foveal floor width (FFW) and minimal foveal thickness defined foveal pit morphologic features of the fellow eye. MAIN OUTCOME MEASURES: Baseline characteristics, SD OCT measurements, and preoperative variables were compared to determine their relationship with idiopathic MH size and postoperative visual acuity (VA) in logarithm of the minimum angle of resolution units. RESULTS: Foveal floor width was correlated with MLD (r = 0.36; P ≤ 0.001) and BD (r = 0.30; P ≤ 0.001), but not postoperative VA. Minimum linear diameter correlated with preoperative VA (r = 0.49; P ≤ 0.0001) and postoperative VA (r = 0.54; P ≤ 0.0001). A 2-stage regression model was developed to predict postoperative VA (r2 = 0.28): preoperative VA (ß = 0.36; P = 0.002) explained 13% of variability and MLD (ß = 0.29; P = 0.002), and idiopathic MH duration (ß = 0.23; P = 0.004) explained a further 16%. CONCLUSIONS: Foveal floor width of the fellow eye in patients with a unilateral idiopathic MH was correlated significantly with idiopathic MH size and may explain some of the variability in idiopathic MH size observed between individuals. However, FFW could not predict postoperative vision.

Determinants of vitreomacular traction width: associations with foveal floor width and vitreoretinal interface changes.

To investigate the relationship between vitreomacular traction (VMT) width, foveal floor width (FFW) and other anatomical characteristics between eyes of patients with VMT. Retrospective observational study of unilateral and bilateral VMT cases from two specialist ophthalmic centres in the United Kingdom (UK) between 2016 and 2018. For unilateral VMT cases: VMT width in the affected eye and FFW in the non-affected fellow eye were measured. In bilateral VMT cases: VMT width in both eyes was measured. In all cases, the presence of any associated inner or outer retinal, and vitreoretinal interface (VRI) changes, including epiretinal membrane, was also documented. 88 patients fulfilled the study criteria: 57 having unilateral and 31 bilateral VMT. For unilateral VMT cases, log (VMT) width was significantly correlated with FFW (r = 0.347, p = 0.008). Using stepwise linear regression, FFW (p = 0.004) and VRI changes (p = 0.03) were both significantly associated with VMT width with a R2 of 0.21. In bilateral VMT cases, there was strong positive correlation between log (VMT) width (r = 0.88, p < 0.001), and the presence of any VRI (r = 0.90, p < 0.001) or outer retinal changes (r = 0.50, p < 0.001) between the two eyes. These findings suggest that individual variations in foveal morphology as measured by the FFW, along with the presence of vitreoretinal interface changes, are associated with the extent of VMT width. VMT width, VRI and outer retinal changes were also highly correlated between eyes in bilateral VMT, suggesting that individual patient factors, which may be genetic or acquired, determine their presence and extent.

OUTCOME OF REVISION PROCEDURES FOR FAILED PRIMARY MACULAR HOLE SURGERY.

PURPOSE: To analyze the outcomes of revision surgery for idiopathic full-thickness macular holes that have failed to close after primary surgery, and also to assess factors predicting success and to review the relative effect of adjunctive surgical techniques. METHODS: A multicenter retrospective study. Anatomical closure rates and visual acuity change between pre and postrevision surgery were assessed. Hole size, age, symptom duration, surgical interval, and reduced hole size were analyzed as predictive factors for success. Effectiveness of adjunctive surgical techniques was reviewed. RESULTS: Seventy-seven eyes were included in the study. Anatomical closure was achieved in 71% (55/77) cases. There was a median gain of 11 Early Treatment of Diabetic Retinopathy Score letters in all holes and 14 letters in closed holes. Full-thickness macular holes that increased in size by more than 10% following primary surgery had a closure rate of 50% compared with 80% in holes that reduced by 10% or stayed the same (P = 0.015). Increasing hole size is associated with a modest reduction in odds of closure (odds ratio = 0.99; P = 0.04). Surgical interval <2 months is not associated with better outcomes compared with >2 months (P = 0.14). CONCLUSION: Revision surgery for full-thickness macular holes that have failed to close after primary surgery is associated with high closure rates and significant visual gains.

New features in MEK retinopathy.

BACKGROUND: The use of molecularly targeted therapy is becoming widespread in oncology. These agents cause tumour-specific genetic alterations in signal transduction pathways, hence less generalised toxicity. Dabrafenib, a BRAF inhibitor and Trametinib, a MEK inhibitor are two molecularly targeted agents recently approved for treatment of advanced, unresectable melanomas. MEK retinopathy is a recently introduced term describing retinal toxicity secondary to MEK inhibitors. CASE PRESENTATION: A 71-year-old man presented with 'circular, green patches' in his central vision for 2 weeks. He had multiple relapsed stage IV BRAF gene mutant malignant melanoma. He was on treatment with Dabrafenib (Tafinlar) for 7 months and Trametinib (Mekinist) for 4 months respectively. The fundus looked normal. The OCT scan showed bilateral symmetrical cystoid macular edema, intraretinal and subretinal fluid, thickening of elliposoid zone and subretinal granular deposits. The symptoms resolved with temporary cessation of chemotherapy but OCT signs persisted. CONCLUSION: This case report identifies two new remarkable features of MEK retinopathy as thickening of ellipsoid zone and 'starry sky' pattern of distribution of subretinal granular deposits. These changes signify photoreceptors/ RPE toxicity and dysfunction. The subretinal granular deposits showed increased autofluorescence suggested abnormal lipofuscin clearance due to RPE dysfunction. The molecularly targeted therapy has revolutionized the cancer treatment and increased the survival rate. These agents are relatively new and recently approved for clinical use and most of them are associated with ocular toxicities. Awareness of ocular symptoms, side-effect profile of drugs, monitoring regime and liaison between oncologist and eye care professional with ocular imaging is key to early diagnosis and management of ocular adverse events.

Clinical response of pigment epithelial detachment associated with neovascular age-related macular degeneration in switching treatment from Ranibizumab to Aflibercept.

BACKGROUND: To study the clinical outcomes of pigment epithelial detachment (PED) associated with neovascular age-related macular degeneration (nAMD) in patients switched from Ranibizumab to Aflibercept. METHODS: Retrospective non-comparative case series. 50 eyes with active nAMD and fovea involving PED of ≥100 µm measured manually using the caliper on the OCT, initially treated with intravitreal Ranibizumab (0.5 mg/0.05 ml) and later switched to Aflibercept (2.0 mg/0.05 ml). The outcome measures of best corrected visual acuity (BCVA), PED height, PED width and number of injections were measured at baseline and at time point of switch, 4 months, 1 year and at last follow up visit post-switch. Three paired t-tests and Pearson's correlations were calculated to analyze variables at switch and change in variables at 1 year. RESULTS: After switch to Aflibercept, the improvement of BCVA was 1.84 (p = 0.11), 1.74 (p = 0.21) and 1.16 (p = 0.45) letters, the change in PED height was - 65.6µm (p < 0.001), - 50.64µm (p = 0.007) and - 68.48µm (p < 0.001) and the change in PED width was - 36.6µm (p = 0.514), + 29.7µm (p = 0.922) and + 118.4µm (p = 0.210) at 4 months, 1 year and the last visit respectively. There was a moderate negative correlation between reduction in PED height at 1 year after switch and PED height at the time of switch to Aflibercept (r = - 0.474, p < 0.05). CONCLUSION: The improvement in BCVA and change in PED width was not statistically significant however the reduction in PED height was significant after switching treatment to Aflibercept. The change in BCVA at 1 year after switch was not correlated with any of the analyzed anatomical characteristics of PED.

Retinal features in Mulvihill-Smith syndrome.

BACKGROUND: Mulvihill-Smith syndrome is a rare progeroid syndrome of sporadic nature. Previously reported ophthalmological findings include astigmatism, myopia, endothelial dystrophy, keratoconus, cataract, band keratopathy, meibomian gland dysfunction, dry eye disease, amblyopia, and allergic conjunctivitis. MATERIALS AND METHODS: The proband, a 25-year-old male subject diagnosed with Mulvihill-Smith syndrome in childhood developed retinal changes with onset of adulthood. The retinal changes were monitored for progression with fundus photography, electrodiagnostic tests, and spectral domain optical coherence tomography. RESULTS: The fundus examination revealed grossly normal looking retina with dull foveal reflex. The optical coherence tomography scan of the retina revealed diffuse thickening, schisis, and folding of retinal layers in both eyes. The structural changes in retina were progressive with wrinkling of inner retinal layers and loss of foveal contour as observed over 3 years. The electrodiagnostic tests revealed normal photoreceptor-retinal pigment epithelial interface. CONCLUSIONS: This is the first report of retinal features in Mulvihill-Smith syndrome. These ocular changes coincided with other systemic changes with the onset of adulthood. These changes may indicate the natural history of retinal features in this progeria syndrome with short life span. The detailed analysis and progression of structural changes in retina is possible with optical coherence tomography.

Association of anemia and mineral and bone disorder with health-related quality of life in Asian pre-dialysis patients.

BACKGROUND: Patients with chronic kidney disease (CKD) have poor health-related quality of life (HRQoL). The association of CKD-related complications such as anemia and mineral and bone disorders (MBD) with HRQoL in pre-dialysis patients is not well-studied. As such, this study aimed to determine the association of anemia and MBD with HRQoL in pre-dialysis patients. METHODS: This was a cross-sectional study involving 311 adult pre-dialysis patients with stage 3-5 CKD from an acute-care hospital in Singapore. Patients' HRQoL were assessed using Kidney Disease Quality of Life Short Form (KDQOL-SF™) and EuroQol 5 Dimensions-3 levels (EQ5D-3L). HRQoL between patients with and without anemia or MBD were compared by separate hierarchical multiple linear regression analyses using various HRQoL scales as dependent variables, adjusted for sociodemographic, clinical and psychosocial variables. RESULTS: After adjusting for MBD, anemia was associated with lower HRQoL scores on work status (WS), physical functioning (PF) and role physical [ß (SE): -10.9 (4.18), p = 0.010; -3.0 (1.28), p = 0.018; and -4.2 (1.40), p = 0.003, respectively]. However, significance was lost after adjustments for sociodemographic variables. Patients with MBD had poorer HRQoL with respect to burden of kidney disease, WS, PF and general health [(ß (SE): -7.9 (3.88), p = 0.042; -9.5 (3.99), p = 0.018; -3.0 (1.22) p = 0.014; -3.6 (1.48), p = 0.015, respectively]. Although these remained significant after adjusting for sociodemographic variables, significance was lost after adjusting for clinical variables, particularly pill burden. This is of clinical importance due to the high pill burden of CKD patients, especially from medications for the management of multiple comorbidities such as cardiovascular and mineral and bone diseases. CONCLUSIONS: Neither anemia nor MBD was associated with HRQoL in our pre-dialysis patients. Instead, higher total daily pill burden was associated with worse HRQoL. Medication reconciliation should therefore be routinely performed by clinicians and pharmacists to reduce total daily pill burden where possible.

Adder bite on eyelid along with retained intraorbital fangs.

PURPOSE: Snake bite to the eye is a rare event. Most cases reported in the literature are due to boa constrictor bites. This is a rare case of snake bite from a common adder (Vipera berus) to the ocular adnexa along with a retained intraorbital tooth. METHOD: A 57-year-old man presented with a history of being bitten by an adder in the left eye upper lid 12 days previously while bending down to pick up a log at his farm. He developed a firm, tender lump in the medial part of his left upper eyelid. RESULT: A CT scan revealed an extraconal curved calcific dense foreign body, about 5 mm in length consistent with adder's tooth in the superomedial part of left orbit. CONCLUSION: There are few reports of adder bites on face, ear and neck. We report a rare case of adder bite on eyelid along with retained intraorbital fangs and its clinical outcome.

Intraoperative clouding of a posterior chamber intraocular lens.

The glistening and delayed opacification of intraocular lenses (IOLs) has been reported in literature as a late and permanent change in the acrylic IOL due to temperature change. We report a case in which clouding and opacification of an IOL occurred intraoperatively within a few seconds of implantation into the capsular bag after routine phacoemulsification. This phenomenon occurred due to the sudden change in temperature of a very cold IOL being implanted into the eye at body temperature. The opaqueness lasted for about 3 h then cleared without any residual or permanent change to the IOL. This case highlights the effect of environmental factors on hydrophillic acrylic IOLs. It is particularly important in cold countries and during the winter months. It also reinforces the practice of storing the IOL at a correct temperature to avoid sudden fluctuations in its surrounding environment.

Ocular decompression retinopathy following post-trabeculectomy suture lysis and management with triamcinolone acetonide.

Ocular decompression retinopathy (ODR) is a rare complication of sudden lowering of intraocular pressure (IOP) in glaucoma and ocular hypertension. An 80-year-male, a known case of chronic open-angle glaucoma for 13 years, had his IOP controlled by multiple topical antiglaucoma medications. There was an increase in IOP, progression of optic disc cupping and visual field loss along with cataract over the past 6 months. The patient underwent uneventful phacoemulsification with posterior chamber intraocular lens (PCIOL) and penetrating trabeculectomy. Postoperatively, the trabeculectomy bleb was flat and IOP was 44 mmHg and was not controlled by bleb massage. Bleb needling and suture lysis were performed after 2 weeks. The IOP dropped from 44 to 6 mmHg. Three days later the patient presented with a sudden decline in visual acuity (VA) from 0.5 to 1.225 logMAR. The fundus showed multiple retinal haemorrhages resembling ODR. Choroidal detachment also occurred after 3 weeks. Optical coherence tomography confirmed the presence of macular oedema which was treated with an orbital floor triamcinolone acetonide injection (OFTA). The haemorrhages, choroidal detachment and macular oedema resolved and VA improved in 6 months. This is the first case report of ODR following suture lysis and needling after an uneventful combined phacoemulsification with PCIOL implant and trabeculectomy. It also highlights the role of OFTA injections in the management of ODR.

Subconjunctival Loa loa.

Loa loa (commonly known as the 'African eye worm') is a nematode commonly found in areas in and around the rainforests and swamps of Western and Central Africa. In recent years, due to an increase in international travel and migration various 'exotic' tropical diseases are being reported all over the world especially in Europe and North America. So far there have been no recent cases reported from the UK. This case report highlights one such case of Loa loa diagnosed recently in the UK. These filarial diseases should be considered in patients who present with unusual ocular or systemic symptoms if they have migrated or travelled from endemic areas in the recent past.

Ocular and non-ocular manifestations of hypohidrotic ectodermal dysplasia.

Hypohidrotic ectodermal dysplasia (HED) is a group of rare multisystemic genetic syndromes that affects ectodermal structures such as skin, hair, nails, teeth and sweat glands. The authors present a case of a child with ocular and dermatological signs of HED along with severe involvement of other multiple organ systems. The family history could be traced to four generations and there was an observed trend of increase in severity of signs and symptoms occurring at younger age. The purpose of this case report is to create awareness in ophthalmic community of its diagnosis and clinical manifestations. This case highlights the role of multidisciplinary approach for management of systemic disease, genetic evaluation of affected individuals and carriers and genetic counselling.

Extracorporeal removal of toxins.

Holubek et al. reviewed data on extracorporeal removal (ECR) of toxins from the Toxic Exposure Surveillance System (TESS) from 1985 to 2005. Hemodialysis use increased, but hemoperfusion nearly disappeared. Lithium, ethylene glycol, salicylate, and, increasingly, acetaminophen still often necessitate hemodialysis; ECR for theophylline has disappeared. TESS data do not separate continuous renal replacement therapy from hemodialysis, and not all poisonings were reported in this system. Nonetheless, these trends are useful to the nephrology community.