Adjunctive intravitreal dexamethasone in the treatment of acute endophthalmitis following cataract surgery

Edward F Hall1, Garrett R Scott1, David C Musch1,2, David N Zacks11Department of Ophthalmology and Visual Sciences, Medical School; 2Department of Epidemiology, School of Public Health; University of Michigan, Ann Arbor, MI, USAPurpose: Controversy exists regarding the use of intravitreal dexamethasone (IVD) as an anti-inflammatory adjunct to intravitreal antibiotics in patients with acute endophthalmitis following cataract surgery. The purpose of this project was to evaluate our experience regarding the effect of adjunctive IVD use on visual outcomes in such patients.Design: Retrospective, comparative case series.Methods: Study population: Patients treated for acute endophthalmitis following cataract surgery from 1995–2004. Intervention: In addition to standard intravitreal antibiotic treatment, some patients also received a single adjunctive injection of IVD. Primary outcome measures: Median visual acuity at last follow-up and percentage of patients achieving a ≥3-line improvement in visual acuity. Secondary outcome measures: Inflammatory index scoring, including amount of cell and flare, height of hypopyon, and presence of fibrin as a function of time after treatment.Results: Twenty-six eyes were treated with and 38 eyes without adjunctive IVD. Median presenting visual acuity was Hand Motion in both groups. Median visual acuity at last followup measured 20/40 in the IVD group and 20/50 in the No-IVD group (p = 0.75). Seventy-three percent of patients in the IVD group and 82% of patients in the No-IVD group achieved a ≥3-line improvement in visual acuity (p = 0.42). No significant difference was detected between the IVD and No-IVD groups for any of the three measures of inflammation.Conclusion: The use of IVD did not significantly improve the final median visual acuity, the chance of achieving a ≥3-line improvement in visual acuity, or the amount of intraocular inflammation. Based on these findings, and the possible detrimental effect of IVD on visual outcomes previously reported in the literature, the use of IVD does not appear to be warranted as a routine adjunctive treatment in postoperative endophthalmitis.Keywords: endophthalmitis, dexamethasone, intravitreal injectio

Age related macular degeneration in monozygotic twins and their spouses in Iceland

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72814/1/j.1600-0420.1999.770413.x.pd

Estimating minimally important differences for two visionspecific quality of life measures,”

PURPOSE. To estimate minimally important differences (MIDs) for the Visual Activities Questionnaire (VAQ) and the National Eye Institute-Visual Function Questionnaire (NEI-VFQ). METHODS. A total of 607 subjects with newly-diagnosed open-angle glaucoma (OAG) was enrolled in the Collaborative Initial Glaucoma Treatment Study (CIGTS) and randomized to initial treatment with medications or surgery. Subjects underwent an ophthalmic examination and telephone-administered quality of life (QOL) interview before randomization and every six months thereafter. The VAQ and NEI-VFQ were used to assess participants' perceptions of their visual function. Clinical measures included the mean deviation (MD) from Humphrey 24-2 full threshold visual field (VF) testing, and best-corrected visual acuity (VA) measured using the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol. Anchor-based (using MD and VA) and distribution-based methods were used to estimate MIDs. RESULTS. Anchor-based cross-sectional analyses at 66 months follow-up found a 10-letter increment in better eye VA corresponded to MIDs of 5.2 units for VAQ and 3.8 units for NEI-VFQ total scores. A 3-dB increment in the better eye MD yielded MIDs of 2.6 and 2.3 units for the same two questionnaires. In longitudinal analyses, MIDs for the VAQ were 3.2 units for a 10-letter change of VA and 3.4 units for a 3-dB change in the MD. Distribution-based MIDs were larger. CONCLUSIONS. A range of MIDs for the VAQ (2.6-6.5 units) and NEI-VFQ (2.3-3.8 units) was found. Although similar in magnitude, MIDs were sensitive to the MID estimation method, the anchor chosen, and differences between questionnaires. (ClinicalTrials.gov number, NCT00000149.

Filtering data from the collaborative initial glaucoma treatment study for improved identification of glaucoma progression

Abstract Background Open-angle glaucoma (OAG) is a prevalent, degenerate ocular disease which can lead to blindness without proper clinical management. The tests used to assess disease progression are susceptible to process and measurement noise. The aim of this study was to develop a methodology which accounts for the inherent noise in the data and improve significant disease progression identification. Methods Longitudinal observations from the Collaborative Initial Glaucoma Treatment Study (CIGTS) were used to parameterize and validate a Kalman filter model and logistic regression function. The Kalman filter estimates the true value of biomarkers associated with OAG and forecasts future values of these variables. We develop two logistic regression models via generalized estimating equations (GEE) for calculating the probability of experiencing significant OAG progression: one model based on the raw measurements from CIGTS and another model based on the Kalman filter estimates of the CIGTS data. Receiver operating characteristic (ROC) curves and associated area under the ROC curve (AUC) estimates are calculated using cross-fold validation. Results The logistic regression model developed using Kalman filter estimates as data input achieves higher sensitivity and specificity than the model developed using raw measurements. The mean AUC for the Kalman filter-based model is 0.961 while the mean AUC for the raw measurements model is 0.889. Hence, using the probability function generated via Kalman filter estimates and GEE for logistic regression, we are able to more accurately classify patients and instances as experiencing significant OAG progression. Conclusion A Kalman filter approach for estimating the true value of OAG biomarkers resulted in data input which improved the accuracy of a logistic regression classification model compared to a model using raw measurements as input. This methodology accounts for process and measurement noise to enable improved discrimination between progression and nonprogression in chronic diseases.http://deepblue.lib.umich.edu/bitstream/2027.42/109450/1/12911_2013_Article_773.pd

Plasticity of microvascular oxygenation control in rat fast-twitch muscle: effects of experimental creatine depletion

Aging, heart failure and diabetes each compromise the matching of O2 delivery (QO2)-to-metabolic requirements (O2 uptake, VO2) in skeletal muscle such that the O2 pressure driving blood-myocyte O2 flux (microvascular PO2, PmvO2) is reduced and contractile function impaired. In contrast, β-guanidinopropionic acid (β-GPA) treatment improves muscle contractile function, primarily in fast-twitch muscle (Moerland and Kushmerick, 1994). We tested the hypothesis that β-GPA (2% wt/BW in rat chow, 8 wk; n=14) would improve QO2-to-VO2 matching (elevated PmvO2) during contractions (4.5 V @ 1 Hz) in mixed (MG) and white (WG) portions of the gastrocnemius, both predominantly fast-twitch). Compared with control (CON), during contractions PmvO2 fell less following β-GPA (MG -54%, WG -26%, p<0.05), elevating steady-state PmvO2 (CON, MG: 10±2, WG: 9±1; β-GPA, MG 16±2, WG 18±2 mmHg, P<0.05). This reflected an increased QO2/VO2 ratio due primarily to a reduced VO2 in β-GPA muscles. It is likely that this adaptation helps facilitate the β-GPA-induced enhancement of contractile function in fast-twitch muscles

Personalized behavior change program for glaucoma patients with poor adherence: a pilot interventional cohort study with a pre-post design

Abstract Background About half of people with glaucoma do not adhere to their recommended medications. Interventions for other chronic conditions have successfully utilized reminder systems and motivational interviewing (MI)-based counseling. This study was designed to pilot a personalized intervention that leverages these strategies to assess their impact on medication adherence in glaucoma patients. Methods Glaucoma patients taking ≥ 1 medication will be pre-screened by telephone survey for adherence to their medication(s). Those who self-report poor adherence will be enrolled in a 3-month monitoring period to measure medication adherence using electronic medication monitors. Participants who are non-adherent (take </=80% of their medication doses) over the 3-month run in phase will be eligible for the study. We plan to enroll 57 participants who are non-adherent to their medications. Participants’ adherence will then be continuously measured with electronic medication monitors, by self-report, and via pharmacy refill data over 2 years, during which two successively more resource-intensive components of an intervention aimed to improve medication adherence will be administered. The first component is a 3-month period of reminders (audio and/or visual) and text message or automated phone call if a dose of medication is not taken within a pre-specified time frame. The second component is a 6-month MI-based counseling program with a trained glaucoma counselor. This component uses the eyeGuide, a computer-based personalized behavior change program that enables para-professional staff to provide personalized education and counseling for glaucoma. The primary outcome is change in medication adherence. The secondary outcomes include changes in clinical outcomes (intraocular pressure, IOP, and IOP fluctuation) and psychosocial mediators of adherence (e.g., competence, energy for change and satisfaction). Participants will undergo semi-structured interviews at 12 months to give feedback about the counseling program in order to improve it. Discussion This pilot study will provide insight into ways to deliver more personalized health care to non-adherent glaucoma patients in order to better support them in managing their chronic disease. Trial registration Retrospectively registered with ClinicalTrials.gov ( NCT03159247 ).https://deepblue.lib.umich.edu/bitstream/2027.42/145182/1/40814_2018_Article_320.pd

Eye Care Providers' Attitudes Towards Tele-ophthalmology

Background: The rapid rise of e-health and remote care systems will likely change the practice patterns of ophthalmologists. Although telemedicine practices are thriving in many specialties of medicine, telemedicine for ophthalmology has been limited primarily to asynchronous care for diabetic retinopathy. The goal of this research was to evaluate perspectives on and familiarity with telemedicine among eye care providers at a large tertiary-care medical center via an anonymous, descriptive survey. Results: In total, 58 eye care physicians completed surveys (response rates of 86% for physicians-in-training and 49% for faculty physicians, respectively). Although a majority of both faculty and physicians-in-training were willing to participate in telemedicine services, trainees were more likely to be willing to interpret photographs than faculty (p=0.04). Most respondents (71%) indicated that they did not use telemedicine. Over half had received photographs (via phone or e-mail) for interpretation from referring physicians (54%) or patients (56%) within the past 3 months. A majority of providers (82%) would be willing to participate in telemedicine for consultations and for interpreting photographs, but a majority (59%) had low confidence in remote care for providing an opinion on patient care. Conclusions: Most eye care providers viewed telemedicine as part of the future of eye care but were concerned about the use of telemedicine. Although most providers did not practice telemedicine, over half of them were comfortable managing eye care consultations (including patients' photographs) via the Internet.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140282/1/tmj.2014.0115.pd

Concordance of Aqueous Humor Flow in the Morning and at Night in Normal Humans

PURPOSE. To test the hypothesis that an individual shows concordance of aqueous humor flow in the morning and at night in a prospective inpatient fluorophotometry study in healthy subjects. METHODS. Flow was measured in each eye every hour between 8 AM and noon and every 2 hours between midnight and 6 AM. Morning and nighttime flows were analyzed for differences between eyes and for differences between these two time points. Concordance of individual morning and nighttime flows were studied by categorization into low, medium, or high tertiles, dot plot, and ordinary least-squares regression (OLS) scatter plot. RESULTS. In 28 subjects, the flow was similar between eyes within a subject with healthy eyes. In the one eye examined in each subject, the average flow was 3.12 Ϯ 1.09 L/min in the morning, which decreased significantly to 1.59 Ϯ 0.58 L/min at night. During each time period, the individual flow data were normally distributed. Concordance of an individual&apos;s morning and nighttime flows was 68%. A scatter plot of morning versus nighttime flows also supported concordance with an OLS regression fit of r 2 ϭ 0.45. CONCLUSIONS. The results provide evidence that aqueous humor flow is similar between eyes, that flow variation shows a normal distribution, and that individuals show a concordance of flow in the morning and at night. These observations support the posit that aqueous humor flow, which is a factor that contributes to the important clinical risk factor of IOP variation, is amenable to study as a quantitative trait. (Invest Ophthalmol Vis Sci. 2006;47: 4860 -4864

The effects of dietary fish oil on exercising skeletal muscle vascular and metabolic control in chronic heart failure rats

The ATP-sensitive K+ (KATP) channel is a class of inward rectifier K+ channels that can link cellular metabolic status to vasomotor tone across the metabolic transients seen with exercise. This investigation tested the hypothesis that if KATP channels are crucial to exercise hyperaemia then blockade via glibenclamide (GLI) would lower hindlimb skeletal muscle blood flow (BF) and vascular conductance (VC) during treadmill exercise. In 14 adult male Sprague Dawley rats mean arterial pressure (MAP), blood [lactate], and hindlimb muscle BF (radiolabelled microspheres) were determined at rest (n = 6) or during exercise (n = 8; 20 m min⁻¹, 5% incline) under control (CON) and GLI conditions (5 mg kg⁻¹, i.a). At rest and during exercise, MAP was higher (Rest, CON: 130 ± 6, GLI: 152 ± 8; Exercise, CON: 140 ± 4, GLI: 147 ± 4 mmHg, P < 0.05) and heart rate (HR) was lower (Rest, CON: 440 ± 16, GLI: 410 ± 18; Exercise, CON: 560 ± 4, GLI: 540 ± 10 beats min⁻¹, P < 0.05) with GLI. Hindlimb muscle BF (CON: 144 ± 10, GLI: 120 ± 9 ml min⁻¹ (100 g)⁻¹, P < 0.05) and VC were lower with GLI during exercise but not at rest. Specifically, GLI decreased BF in 12, and VC in 16, of the 28 individual hindlimb muscles and muscle parts sampled during exercise with a greater fractional reduction present in muscles comprised predominantly of type I and type IIa fibres (P < 0.05). Additionally, blood [lactate] (CON: 2.0 ± 0.3; GLI: 4.1 ± 0.9 mmol L⁻¹, P < 0.05) was higher during exercise with GLI. That KATP channel blockade reduces hindlimb muscle BF during exercise in rats supports the obligatory contribution of KATP channels in large muscle mass exercise-induced hyperaemia