Case Report: Multimodal, Longitudinal Assessment of Retinal Structure and Function following Laser Retinal Injury.

SIGNIFICANCE: This case report demonstrates the use of novel imaging techniques and functional tests to longitudinally evaluate retinal structure and function after laser retinal injury. The structural and functional prognosis could be predicted with clinical findings, high-resolution retinal imaging, and functional testing. PURPOSE: We present a laser retinal injury case in which an adaptive optics scanning laser ophthalmoscope and adaptive optics-based psychophysics were used to examine and monitor retinal structure and function after accidental exposure to a 1-W infrared laser beam. CASE REPORT: A 23-year-old patient was unwittingly exposed to a 1-W, 852-nm continuous-wave laser at work as they noticed a small central blurry spot in the right eye. An initial eye examination was done 1 day after exposure, and the right eye's acuity was 20/25 -2 . Posterior segment evaluation revealed disrupted outer retina near the right eye's fovea. Adaptive optics imaging 2 weeks after the exposure revealed a 0.50 × 0.75° elliptical area with irregular borders and abnormal cone reflectivity just below the fovea. Starting at 1-month follow-up, structural recovery was observed on optical coherence tomography (OCT). Subsequent adaptive optics imaging showed significant recovery of cone reflectivity. Importantly, adaptive optics microperimetry showed measurable detection thresholds at all affected retinal locations at 6 months. By 10 months, all sites exhibited normal sensitivities. CONCLUSIONS: Retinal structure and function from laser injury can be visualized and measured with OCT, adaptive optics imaging, and psychophysics. An intact Bruch's membrane on OCT and measurable retinal sensitivity by adaptive optics microperimetry may serve as good biomarkers for retinal recovery.

The Co-Creation of a Patient Information Leaflet for Patients With the Rare Eye Infection Acanthamoeba keratitis.

Acanthamoeba keratitis (AK) is a rare but severe eye disease. A research engagement event, "The Cornea Day," in London, UK in 2013, identified the lack of credible information about AK and a need for practical day to day management strategies. Experiences of 15 AK patients attending The Cornea Day were distilled into a survey that was administered to a wider group of 76 patients, carers, researchers, and clinicians. A Patient Information Leaflet was cocreated and then represented to additional patients for final modification. The AK Patient Leaflet (revised 2019) is available in several languages and used globally.

Technique for pediatric corneal crosslinking under general anesthesia.

Corneal cross-linking (CXL) is typically performed under topical anesthesia, which may be unsuitable in children and individuals with severe anxiety, poor cooperation, or neurodevelopmental issues. We describe a technique of CXL under general anesthesia that uses sevoflurane and propofol with laryngeal airway or nasal oxygen cannulas, and forceps or microsponges to stabilize the eye position intraoperatively. We also developed a simple and time-saving technique of bilateral simultaneous CXL, whereby the second eye can undergo CXL concurrently with the first in a staggered fashion. Using this technique, we have been able to eliminate up to 25% of surgical time required in standard bilateral procedures. Postoperatively, multimodal analgesia was administered to ensure patient comfort and prevent excessive eye rubbing. In total, 21 eyes of 13 subjects ≤18 years of age were treated. During a median follow-up of 14.5 months (range, 4-43), the only complication observed was sterile corneal infiltrate in 1 eye that resolved with a short course of corticosteroids.

Prospective Study of the Diagnostic Accuracy of the In Vivo Laser Scanning Confocal Microscope for Severe Microbial Keratitis.

PURPOSE: To determine the diagnostic accuracy of in vivo confocal microscopy (IVCM) for moderate to severe microbial keratitis (MK). DESIGN: Double-masked prospective cohort study. PARTICIPANTS: Consecutive patients presenting to Aravind Eye Hospital, Madurai, India, between February 2012 and February 2013 with MK (diameter ≥3 mm, excluding descemetocele, perforation, or herpetic keratitis). METHODS: Following examination, the corneal ulcer was scanned by IVCM (HRT3/RCM, Heidelberg Engineering, Heidelberg, Germany). Images were graded for the presence or absence of fungal hyphae or Acanthamoeba cysts by the confocal microscopist who performed the scan (masked to microbial diagnosis) and 4 other experienced confocal graders (masked to clinical features and microbiology). The regrading of the shuffled image set was performed by 3 graders, 3 weeks later. Corneal-scrape samples were collected for microscopy and culture. MAIN OUTCOME MEASURES: The main outcome measures were sensitivity, specificity, and positive and negative predictive values of IVCM compared with those of a reference standard of positive culture or light microscopy. Sensitivities and specificities for multiple graders were pooled and 95% confidence intervals calculated using a bivariate random-effects regression model. RESULTS: The study enrolled 239 patients with MK. Fungal infection was detected in 176 (74%) and Acanthamoeba in 17 (7%) by microbiological methods. IVCM had an overall pooled (5 graders) sensitivity of 85.7% (95% confidence interval [CI]: 82.2%-88.6%) and pooled specificity of 81.4% (95% CI: 76.0%-85.9%) for fungal filament detection. For Acanthamoeba, the pooled sensitivity was 88.2% (95% CI: 76.2%-94.6%) and pooled specificity was 98.2% (95% CI: 94.9%-99.3%). Intergrader agreement was good: κ was 0.88 for definite fungus; κ was 0.72 for definite Acanthamoeba. Intragrader repeatability was high for both definite fungus (κ: 0.88-0.95) and definite Acanthamoeba classification (κ: 0.63-0.90). IVCM images from 11 patients were considered by all 5 graders to have a specific organism present (10 fungus, 1 Acanthamoeba) but had negative results via culture and light microscopy. CONCLUSIONS: Laser scanning IVCM performed with experienced confocal graders has high sensitivity, specificity, and test reproducibility for detecting fungal filaments and Acanthamoeba cysts in moderate to large corneal ulcers in India. This imaging modality was particularly useful for detecting organisms in deep ulcers in which culture and light microscopy results were negative.

Outbreak of Mycoplasma pneumoniae-Associated Stevens-Johnson Syndrome.

BACKGROUND: Stevens-Johnson syndrome (SJS) is an uncommon, sporadic disease and outbreaks are rare. In November 2013, an outbreak of SJS was identified at Children's Hospital Colorado. METHODS: Outbreak cases were children aged 5-21 with a discharge diagnosis of SJS admitted from September 1 to November 30, 2013. Medical charts were reviewed using standardized data collection forms. Respiratory specimens were tested for viruses and Mycoplasma pneumoniae (Mp) by polymerase chain reaction (PCR). We conducted a separate 4-year retrospective case-control study comparing hospitalized SJS cases with and without evidence of Mp infection. RESULTS: During the outbreak, 8 children met SJS criteria. Median age was 11.5 years (range 8-16 years); 5 (63%) were boys and 5 (63%) were Mp-PCR-positive. Of the 5 PCR-positive children, none had preceding medication exposure, and all had radiographic pneumonia. All outbreak Mp isolates were macrolide susceptible. The retrospective case-control analysis showed that Mp-associated SJS episodes (n = 17) were more likely to have pneumonia (odds ratio [OR] 7.5, confidence interval [CI] 1.6­35.1), preceding respiratory symptoms (OR 30.0, CI 3.3­269.4) [corrected] an erythrocyte sedimentation rate ≥35 mg/dL (OR 22.8, CI 2.1-244.9), and ≤3 affected skin sites (OR 4.5, CI 1.2-17.4) than non-Mp-associated SJS episodes (n = 23). CONCLUSIONS: We report the largest outbreak of SJS in children, which was also predominately associated with Mp infection. Mp-associated SJS was associated with a distinct clinical presentation that included less extensive skin disease, an elevated erythrocyte sedimentation rate, and evidence of a preceding respiratory infection.

An innovative medical and dental hygiene clinic for street youth: results of a process evaluation.

Canada has a noteworthy reputation for high quality health care. Nonetheless, street youth are one of our most vulnerable yet underserved populations. Consequently, a medical and dental clinic was created in downtown Ottawa, Ontario to respond to their needs. The purpose of this study is to describe a process evaluation of the clinic during its first year of operation with a focus on program fidelity, dose, reach, and satisfaction. A mixed methods approach was used involving interviews with providers, focus groups with street youth, analysis of Electronic Medical Record (EMR) data, and supplemental information such as document reviews. The evaluation identified areas that were working well along with challenges to program implementation. Areas of concerns and possible solutions were presented to the management team that then helped to plan and make improvements to the clinic. Our evaluation design and working relationship with clinic management promoted the integration of real-time evidence into program improvements.

Low-voltage aEEG as predictor of intracranial hemorrhage in preterm infants.

The objectives of this prospective cohort study were to identify amplitude-integrated electroencephalography (aEEG) background patterns predictive of severe intracranial hemorrhage. Thirty ventilated preterm newborns weighing <1,000 g were assessed by an aEEG cerebral function monitor and ultrasound measurement of cerebral blood flow velocity at time of surfactant administration and tracheal suctioning simultaneously during first 48 hours of life. Birth weight was 624 ± 200 g (mean ± S.D.) and gestational age was 25 ± 2 weeks. Background electrical activity was predominantly discontinuous in 72% of infants. A sharp increase in electrical activity/burst density was observed during surfactant administration and tracheal suctioning in most infants, with a 33.5% increase in mean cerebral blood flow velocity. Burst suppression with low voltage was identified in 57% infants with severe intracranial hemorrhage, whereas no infant without hemorrhage exhibited this pattern (P = 0.014). We conclude that aEEG low-voltage burst suppression might have useful clinical applications with 100% positive predictive value for severe intracranial hemorrhage.

Effect of low and high fat diets on nutrient intakes and selected cardiovascular risk factors in sedentary men and women.

OBJECTIVE: The desired level of dietary fat intake is controversial. The effect of decreasing fat intake to 19% and increasing it to 50% from a control diet of 30% on nutritional status and cardiovascular risk factors in healthy individuals was studied. METHODS: Eleven healthy subjects (5 men and 6 women) were randomized to consume diets with 19% and 50% calories from fat. Each diet lasted 3 weeks, with a one-week washout. The habitual and washout diets were determined to be 30% fat. At the beginning and the end of each diet, fasting blood was collected to determine plasma lipoproteins, and physiological factors were measured. RESULTS: Total caloric expenditure was similarly balanced to intake on the 30% and 50% fat diets, but intake was significantly lower on the 19% fat diet and led to a loss of 0.6 kg body weight. Consumptions of essential fatty acids, vitamin E and zinc were improved with increased fat intake, but folate intake was compromised on the 30% and 50% fat diets. Compared with the 50% fat diet, subjects consuming the 19% fat diet had significantly lower HDL cholesterol (HDL-C) (54 +/- 3 vs. 63 +/- 3 mg. dL(-1), p < 0.05) and apolipoprotein A1 (ApoA1) (118 +/- 4 vs. 127 +/- 3 mg/dL, p < 0.05). Changing the levels of fat intake did not affect % body fat, heart rate, blood pressure, blood triglycerides, total cholesterol (TC), LDL cholesterol, apolipoprotein B (ApoB), TC/HDL-C and ApoA1/ApoB ratios. CONCLUSION: A low fat diet (19%) may not provide sufficient calories, essential fatty acids, and some micronutrients (especially vitamin E and zinc) for healthy untrained individuals, and it also lowered ApoA1 and HDL-C. Increasing fat intake to 50% of calories improved nutritional status, and did not negatively affect certain cardiovascular risk factors.