The role of clinical parapapillary atrophy evaluation in the diagnosis of open angle glaucoma

Joshua R Ehrlich, Nathan M RadcliffeDepartment of Ophthalmology, Weill Cornell Medical College, New York, NY, USAPurpose: To determine if clinical evaluation of parapapillary atrophy (PPA) significantly improves the ability to distinguish open-angle glaucoma (OAG) patients from glaucoma suspects.Methods: Patients in this study were under evaluation for glaucoma and had open angles, at least one reliable 24-2 SITA-standard automatic perimetry, and digital stereophotographs of the optic disc. PPA was identified clinically as a parapapillary region of absent (βPPA) or hyper/hypopigmented (αPPA) retinal pigment epithelium. A single masked observer evaluated photos for: vertical cup-to-disc ratio (CDR), clock hours of total and βPPA, βPPA as percentage width of the optic disc, presence or absence of βPPA at each disc quadrant, and ordinal rating of total PPA. Generalized linear models were used to determine odds of an abnormal or borderline glaucoma hemifield test (GHT) as a function of PPA variables and covariates; model fit was assessed using the log-likelihood ratio test.Results: Of 410 consecutive patients, 540 eyes (of 294 patients) met inclusion criteria. Mean age was greater among patients with abnormal compared with normal GHT (P < 0.001), but sex and race/ethnicity did not differ between groups (P ≥ 0.22). Age, central corneal thickness (CCT) and CDR (P ≤ 0.006), but not intraocular pressure (IOP) (P = 0.71), were significant univariable predictors of the odds of an abnormal GHT. All PPA parameters significantly ­predicted GHT (P ≤ 0.03), except presence of temporal βPPA (P = 0.25). Adjustment for age, CCT, IOP, and CDR reduced the association between PPA and GHT, and model fit was not greatly improved by addition of PPA variables.Conclusions: Addition of most PPA parameters to a model already containing commonly assessed variables including age, CCT, IOP, and CDR does not significantly improve the ability to distinguish OAG patients from glaucoma suspects.Keywords: glaucoma, visual fields, parapapillary atrophy, optic nerv

Intraocular pressure and medication changes associated with Xen gel stent: A systematic review of the literature

The Xen gel stent (Allergan Inc, an AbbVie company; Dublin, Ireland) was conceived as an option for patients requiring modest IOP reduction but for whom trabeculectomy was not yet indicated. As with any glaucoma surgery, establishing criteria for patient selection and identifying factors that contribute to a high likelihood of success are important. To help guide clinical decision-making, a systematic review of published studies on the gel stent was performed, with the goal of understanding postoperative outcomes based on clinical and patient factors. Results were organized around a series of pertinent clinical questions based on scenarios encountered in clinical practice. Criteria for including studies were intentionally broad, with the objective of simulating the diverse population of glaucoma patients encountered in real-world practice. Outcomes for IOP and medication reduction postoperatively were assessed in various analyses, including in eyes with various glaucoma types and severity; in eyes naïve to surgery as well as those with a history of prior incisional glaucoma surgery; and when surgery was performed as a standalone procedure or at the time of cataract surgery. The results of each of the various analyses were consistent in demonstrating that successful gel stent surgery achieved a postoperative IOP of approximately 14.0 mm Hg and reduction to fewer than 1 glaucoma medication. Additional data are shown on outcomes by method of implant (ab interno vs ab externo); intraoperative use of antifibrotics; and rates of needling in published studies

Energy Dose-Response in Selective Laser Trabeculoplasty: A Review

PRCIS: A literature review of SLT energy dose response found no definitive relationship between IOP reduction with respect to total or pulse energy, race, pigmentation, or application pattern. PURPOSE: Selective laser trabeculoplasty (SLT) is a safe and effective treatment for lowering intraocular pressure (IOP). While evidence is mounting for the advantage of its use as a first-line treatment for IOP reduction, the SLT procedures in use vary widely. The purpose of this literature review was to investigate if there were any relationships between SLT energy and efficacy for lowering IOP in the published literature. METHODS: A literature review was undertaken that included studies in which energy levels required for successful SLT treatment were investigated: in general, with respect to angle pigmentation, race or ethnicity, and treatment arc extent. RESULTS: There was no indication that higher (or lower) energy used in the treatment leads to greater (or less) IOP reduction. Similar results were obtained regarding level of trabecular meshwork (TM) pigmentation. Race was not found to be associated with altered dose response in SLT. There were indications that treating the full 360 degrees, as opposed to smaller arcs, could be beneficial for more IOP reduction. IOP reduction from SLT was found to be similar to that provided by topical medications. CONCLUSIONS: The optimal energy level of SLT needed for IOP reduction has not yet been definitively established, with all reported pulse energies resulting in similar IOP reduction. Furthermore, similar lack of conclusive findings exists regarding optimal SLT energy dosage for use in different races and degrees of TM pigmentation. This parameter, as well as each of the above-mentioned factors, requires further research

Faithful chaperones

This review describes the properties of some rare eukaryotic chaperones that each assist in the folding of only one target protein. In particular, we describe (1) the tubulin cofactors, (2) p47, which assists in the folding of collagen, (3) α-hemoglobin stabilizing protein (AHSP), (4) the adenovirus L4-100 K protein, which is a chaperone of the major structural viral protein, hexon, and (5) HYPK, the huntingtin-interacting protein. These various-sized proteins (102–1,190 amino acids long) are all involved in the folding of oligomeric polypeptides but are otherwise functionally unique, as they each assist only one particular client. This raises a question regarding the biosynthetic cost of the high-level production of such chaperones. As the clients of faithful chaperones are all abundant proteins that are essential cellular or viral components, it is conceivable that this necessary metabolic expenditure withstood evolutionary pressure to minimize biosynthetic costs. Nevertheless, the complexity of the folding pathways in which these chaperones are involved results in error-prone processes. Several human disorders associated with these chaperones are discussed

Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland

Background: Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH. Methods: We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression. Results: 175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I–III, modified Fisher 2–4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia. Conclusions: In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care

Impact of Heads-Up Display Use on Ophthalmologist Productivity, Wellness, and Musculoskeletal Symptoms: A Survey Study

PURPOSE: To explore how ophthalmologist productivity, wellness, and musculoskeletal (MSK) symptoms are affected by heads-up display (HUD) use. METHODS: A digital survey was emailed to the United States ophthalmologists. Questions covered topics including MSK health, surgical output, work hours, wellness hours, and factors related to HUD use. RESULTS: One hundred and forty-four ophthalmologists responded, and 99 completed all eligible questions. HUDs were utilized by 33 respondents, 29 of whom submitted complete surveys. HUD users worked 353 more hours annually ( = 0.01) and performed 673 more cases ( = 0.07) than nonusers. MSK symptom presence ( = 0.79), severity ( = 0.80), and frequency ( = 0.86) were independent of use. Over half (n = 16/29) of users identified symptomatic improvement attributable to the device, mostly in the cervical and lumbar regions. Mean job stress was moderate-severe for both users and nonusers ( = 0.10), and there was no significant difference in wellness hours ( = 0.44). Retina specialists ( = 0.02) and males ( = 0.03) were more likely to have operated with the technology. Nearly half of heads-up surgeons (n = 12/29) had obtained new equipment to target MSK symptoms, versus 1.4% of nonusers (n = 1/70; = 0.0009). Most of those who operated with HUDs would recommend them to others (69.0%, n = 20/29), but 44.8% (n = 13/29) indicated ergonomic challenges. Primary concerns included awkward viewing angles, setup difficulties, and a lack of access. CONCLUSIONS: HUD surgeons reported greater work output versus nonusers without significant compromises in wellness or MSK health. User feedback suggests that the technology may lessen neck and low back pains, but barriers including cost and system inconveniences may impede adoption

Digital Survey Assessment of Factors Associated with Musculoskeletal Complaints Among US Ophthalmologists

PURPOSE: To quantify features of musculoskeletal (MSK) complaints among US ophthalmologists and analyze factors related to symptom severity. METHODS: Cornea, glaucoma, retina, and comprehensive practitioners were invited to complete a web-based survey via email. Data on demographics, practice and procedural volumes, wellness activities, job stress, MSK health, the Total Disability Index (TDI), and ergonomics were collected. Significance testing was performed to evaluate factors related to TDI score. RESULTS: Of the 245 ophthalmologists contacted, 58.8% (n = 144) responded at least in part to the survey. Pain episodes were reported in 81.4% (n = 83) of 102 respondents, with 48.1% (n = 49) experiencing daily or weekly attacks. The neck, low back, and shoulders were commonly affected, yet only 57.1% (n=20) of those with shoulder pain reported a corresponding diagnosis. The mean TDI score was 6.2 ± 7.3%, indicating minimal disability related to the spine. Demographics, volume metrics, and wellness hours were each not significantly associated with TDI score (p \u3e 0.05). Higher job stress ratings were reported by those who experienced more frequent pain attacks (p = 0.02) and those with higher TDI scores (p = 0.001). Greater difficulty with clinic, laser, and surgery job tasks was observed in respondents with higher TDI scores (p \u3c 0.001, p = 0.005, and p \u3c 0.001) and more bodily pain locations (p = 0.002, p = 0.002, and p = 0.001). Respondents who pursued practice modifications (p = 0.03) and treatments (p = 0.01) to reduce or prevent pain had higher mean TDI scores, and 94.2% of respondents (n = 97) were interested in learning more about ergonomics. CONCLUSION: Mild MSK complaints were highly prevalent among the surveyed ophthalmologists, and a similar trend could be expected for other US ophthalmologists. Greater frequency and severity of pain may contribute to physician burnout. There may be underdiagnosis of MSK pathology yet also high demand for ergonomic strategies and MSK treatments, suggesting a need for practical solutions