Proptosis in a Patient With Known Graft Versus Host Disease.

A retrospective review of the medical reports of a patient who was undergoing treatment for graft versus host disease following bone marrow transplant for acute myeloid leukemia was conducted. The patient presented with persistent ocular irritation and injection. For an unclear period of time, he developed proptosis and binocular diplopia with limitation of extraocular motility insidiously. MRI revealed gross enlargement of extraocular muscles and bone marrow aspiration trephine confirmed relapse of leukemia. He then underwent chemotherapy with marked improvement of proptosis and extraocular motility. This case report highlights the importance of the eye care provider's careful assessment of patients with a history of malignancy. The presence of ocular irritation must not distract from the detection of other signs. Proptosis and extraocular motility limitation are rarely associated with graft versus host disease. The presence of these signs warrants orbital imaging to rule out recurrence of the primary malignancy.This case report highlights how proptosis and extraocular motility limitation seen in a patient with graft versus host disease may point to recurrence of the primary malignancy.

Case Series: Bilateral Rhegmatogenous Retinal Detachments in Atopic Dermatitis.

SIGNIFICANCE: Bilateral occurrence of rhegmatogenous retinal detachment is a potentially blinding condition seen most commonly in patients with atopic dermatitis. Poor control of the skin condition may lead to simultaneous or sequential retinal detachment and even development of complications such as proliferative vitreoretinopathy. PURPOSE: The purpose of this study was to highlight the importance of the dermatologist's role in aggressive treatment of atopic dermatitis to prevent this potentially blinding condition. CASE REPORTS: A retrospective review of three patients with poorly controlled atopic dermatitis at the Singapore National Eye Centre with bilateral rhegmatogenous retinal detachment was conducted. Two patients presented with sequential rhegmatogenous retinal detachments, and one patient had simultaneous bilateral retinal detachments. At presentation, all three were experiencing atopic dermatitis flares and were either on low-dose oral or topical steroids only. Post-retinal detachment surgery, all eyes except one achieved good visual acuity. The patients were referred to a dermatologist and treated with therapeutic doses of systemic steroids and immunomodulators for their dermatitis flare. CONCLUSIONS: This case series draws attention to the importance of the eye care provider's comanagement of such patients with atopic dermatitis. Aggressive control of facial atopic dermatitis with consideration of immunomodulators or short-term systemic steroids during flares to control facial eczema and eye rubbing may reduce this potentially blinding ocular complication.

Performance of the Moorfields motion displacement test for identifying eyes with glaucoma.

PURPOSE: The Moorfields Motion Displacement Test (MMDT; Enhanced Standard Threshold Algorithm [ESTA] version 1, London, UK) is a new 31-point suprathreshold test for visual field assessment using moving line stimuli displayed on a standard laptop computer. This study evaluated the diagnostic performance of the MMDT for discriminating between healthy eyes and eyes with glaucoma. DESIGN: Evaluation of diagnostic technology. PARTICIPANTS: Seventy-eight subjects with glaucoma and 348 healthy subjects. METHODS: All participants underwent a standardized ophthalmologic examination, including the MMDT and Heidelberg Retina Tomography (HRT; Heidelberg Engineering, Heidelberg, Germany) scanning of the optic disc. The diagnosis of glaucoma was based on clinical examination with glaucomatous optic neuropathy defined by the presence of neuroretinal rim thinning, notching or excavation of the cup, cup-to-disc asymmetry between eyes of 0.25 or more, nerve fiber layer thinning (focal or diffuse), or a combination thereof; and HRT-based Moorfields Regression Analysis (MRA) results of outside normal limits in any sector. Normal eyes were defined as clinically having healthy neuroretinal rims and an MRA analysis of within normal limits in all sectors. The MMDT used a Pandora response version of the ESTA without optical correction. Subjects with a false-positive response of 15% or more in MMDT were excluded. MAIN OUTCOME MEASURES: The performance of the global probability of true damage (global PTD) for diagnosing glaucoma was assessed by sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). The global PTD was calculated as a sum of individual PTD values, ranging from 0% to 100% for all 31 visual locations, and was expressed as a quotient of 100. RESULTS: Seventy-eight subjects with glaucoma (mean age, 66.6±13.1 years; male gender, 55.1%) and 348 healthy subjects (mean age, 55.2±9.2 years; male gender, 35.3%) were analyzed. The AUC for the global PTD was 0.930 (95% confidence interval, 0.893-0.967) for diagnosing glaucoma. At 85% specificity, the MMDT demonstrated a sensitivity of 88.5%. This decreased to 83.3% at 95% specificity. At the global PTD cutoff point value of 2.0, the sensitivity was 85.9% and the specificity was 94.5%. CONCLUSIONS: The suprathreshold MMDT showed good diagnostic performance for diagnosing glaucoma when glaucoma was defined by a structural criterion.

Retinal Vascular Oxygen Saturation and Its Variation With Refractive Error and Axial Length.

PURPOSE: To evaluate the relationships between refractive error, axial length (AL), and retinal vascular oxygen saturation in an adult population. METHODS: This was a hospital-based, prospective observational study. The left eyes of phakic adult subjects without media opacity were analyzed. Subjective undilated manifest refraction was performed, and refractive errors were defined as myopia (spherical equivalent [SE], <-1 D), emmetropia (SE between -1 D and +1 D) and hyperopia (SE >+1 D). Retinal oximetry was performed using the Oxymap system (Oxymap Inc., Reykjavik, Iceland). Multivariate linear regression models were constructed to assess the relationship between retinal vascular oxygen saturation, SE, and AL obtained with optical biometry, with adjustments for age, sex, race, blood pressure, hyperlipidemia, and diabetes mellitus. RESULTS: There were 85 subjects, with mean age of 66.1 ± 11.3 years. The majority were female (60%) and Chinese (84%). A total of 60% were myopic, 28% emmetropic, and 12% hyperopic. Mean SE was -5.29 ± 6.51 D and mean AL was 25.30 ± 2.99 mm. In multivariate analyses, more myopic SE and longer AL were associated with lower retinal arteriolar oxygen saturation (regression coefficient B = 0.61 [95% confidence interval, 0.28, 0.95], P = 0.001; and B = -1.13 [95% confidence interval, -1.71, -0.56], P < 0.001, respectively). Subjects with myopic SE and AL also had lower retinal arteriolar oxygen saturation than emmetropes and hyperopes (P = 0.03 and P = 0.02, respectively). CONCLUSIONS: Eyes with more myopic SE and longer AL have lower retinal arteriolar oxygen saturation. TRANSLATIONAL RELEVANCE: This study provides direct evidence of a link between retinal oxygenation and hypoxia and myopia by using a novel device that quantifies retinal vascular oxygenation in vivo.

Surgical Removal of Internal Limiting Membrane and Layering of AAV Vector on the Retina Under Air Enhances Gene Transfection in a Nonhuman Primate.

Purpose: To determine if the surgical removal of the internal limiting membrane (ILM) in nonhuman primates (NHPs) will result in safe and effective transfection of adeno-associated viral (AAV2) vectors using green fluorescent protein (GFP) as a reporter. Methods: Six Macaca fascicularis NHP eyes underwent vitrectomy, ILM peel with layering of 1.7 × 1013 genome copies per milliliter of AAV2-GFP under air. Four control eyes underwent only vitrectomy and pooling under air. The intensity and area transfected was quantified in vivo with fundus autofluorescence (FAF) imaging. NHPs were euthanized 16 weeks postsurgery and immunohistochemical analysis assessed GFP expression at the cellular level. Results: There was a larger area of fluorescence in ILM peeled eyes then in non-ILM peeled eyes (50.7 [33.1-58.4] pixel2 versus 5.1 [0.6-7.6] pixel2, P < 0.01). The intensity of fluorescence was also higher in ILM peeled eyes (10.3 [2.2-18.5] vs. 1.9 [0.6-4.4], P = 0.05). Non-ILM peeled eyes displayed fluorescence confined to the foveal center. Histological sections showed colocalization in the Müller cell layer, ganglion cell layer, and photoreceptor cell layer in the ILM peeled eyes. In non-ILM peeled eyes GFP expression was only in the ganglion cell layer in three eyes and was confined to the immediate vicinity of the fovea. Conclusions: ILM appears to be the predominate barrier to AAV transfection. An efficacious and safe method of AAV2 gene delivery, taking into account the potential need for repeat treatments, appears to be the surgical removal of ILM and layering of AAV under air.v.

Retinal vessel oxygen saturation increases after vitrectomy.

PURPOSE: To evaluate the effects of vitrectomy on retinal vascular oxygen saturation in an adult population. METHODS: This was a prospective observational study. Twenty-seven eyes of 27 patients who underwent vitrectomy for macular conditions were included. Retinal oximetry was performed using the Oxymap system prior to vitrectomy and 3 months after surgery and the mean retinal arterial and venous oxygen saturation were measured. The arterial-venous difference (AVD) was calculated as the difference between the arterial and venous saturations. Multivariate linear regression models were constructed to compare oxygen saturation before and after surgery, with adjustments for age, sex, hypertension, hyperlipidemia, diabetes mellitus, and indication for surgery. RESULTS: The mean age of the subjects was 68.4 ± 8.9 years, 15 (55%) were male and the majority were of Chinese ethnicity (93%). The mean arterial saturation increased significantly after vitrectomy (101.93 ± 8.36% vs. 96.16 ± 14.14%, P = 0.01). The mean venous saturation also increased significantly after surgery (59.76 ± 8.52% vs. 50.40 ± 11.72%, P = 0.02). The mean AVD significantly decreased from 45.76 ± 12.18% before surgery to 42.17 ± 10.94% after surgery (P = 0.02). CONCLUSIONS: Retinal arterial and venous oxygen saturation are significantly increased after vitrectomy, while the AVD is decreased after vitrectomy.

Risk scoring for prediction of acute cardiac complications from imbalanced clinical data.

Fast and accurate risk stratification is essential in the emergency department (ED) as it allows clinicians to identify chest pain patients who are at high risk of cardiac complications and require intensive monitoring and early intervention. In this paper, we present a novel intelligent scoring system using heart rate variability, 12-lead electrocardiogram (ECG), and vital signs where a hybrid sampling-based ensemble learning strategy is proposed to handle data imbalance. The experiments were conducted on a dataset consisting of 564 chest pain patients recruited at the ED of a tertiary hospital. The proposed ensemble-based scoring system was compared with established scoring methods such as the modified early warning score and the thrombolysis in myocardial infarction score, and showed its effectiveness in predicting acute cardiac complications within 72 h in terms of the receiver operation characteristic analysis.

Clinical audit of the microbiology of otorrhoea referred to a tertiary hospital in Singapore.

INTRODUCTION: Otorrhoea is a common complaint in Ear, Nose and Throat clinics. This study aimed to establish the pathogens involved in cases of otorrhoea in Singapore, their sensitivity patterns and the effectiveness of empirical management. METHODS: A retrospective chart review was conducted on 91 patients with otorrhoea who had undergone swab cultures between July 2010 and February 2011. RESULTS: Of the 91 cases, 53% were diagnosed empirically as bacterial otitis externa and 25% as otomycosis. Aerobic bacteria accounted for 35.8% of the microorganisms cultured, while 34.7% were fungi and 29.5% were anaerobic bacteria. Pseudomonas (P.) aeruginosa and Staphylococcus (S.) aureus made up 31.6% and 21.0% of the microorganisms, respectively. 20% of S. aureus grown was methicillin-resistant. Aspergillus was the most common fungus and 19% of cultures were polymicrobial. 38% of patients had their treatment changed on the basis of culture results, as no improvement was observed on follow-up. P. aeruginosa was sensitive to ciprofloxacin and gentamicin in 81.8% and 76.0% of patients, respectively, while S. aureus was sensitive to cloxacillin in 93.8% and clindamycin in 87.5% of patients. CONCLUSION: The common microorganisms involved in otorrhoea in Singapore are P. aeruginosa, Aspergillus and S. aureus. Resistant strains of Pseudomonas spp. are now present. Methicillin-resistant S. aureus is increasingly prevalent and highly sensitive to vancomycin. Aminoglycoside and fluoroquinolone-containing eardrops are suitable first-line topical antimicrobials. Cloxacillin may be started should a concomitant oral antimicrobial be warranted empirically or for S. aureus infections. Otomycosis should be considered in patients who show no improvement with antibiotics.