Amir L. Butt

Topical Interferon or Surgical Excision for the Management of Primary Ocular Surface Squamous Neoplasia

OBJECTIVE To describe the successful treatment and long-term outcomes of primary ocular surface squamous neoplasia (OSSN) with topical interferon alfa-2b or surgical excision. DESIGN Retrospective, comparative, interventional case series. PARTICIPANTS Twenty-nine consecutive patients with OSSN never before treated. INTERVENTION Patients with primary OSSN chose topical interferon alfa-2b or excision with wide surgical margins, with crossover to surgery in those interferon-treated patients whose OSSN failed to regress within 2 months after beginning therapy. MAIN OUTCOME MEASURES Successful resolution of clinical disease at 2 months after topical interferon treatment and time to recurrence after either topical interferon or surgical excision. RESULTS Of 29 patients with primary OSSN, 15 elected topical interferon and 14 chose surgical excision. Two patients in the interferon group subsequently underwent surgical excision for apparent lack of response to interferon. No patient in either group developed a recurrence during the study period (disease-free follow-up: interferon group, mean, 35.6 months [95% confidence interval, 21.9-49.3]; surgery group, mean, 35.6 months [22.9-48.3]). CONCLUSIONS Both topical interferon alfa-2b and aggressive surgical excision appear to be effective for primary OSSN.

Adenoviral keratoconjunctivitis in a tertiary care eye clinic.

Purpose: To elucidate the natural history and epidemiology of adenoviral keratoconjunctivitis as seen in a tertiary care eye clinic. Methods: In a retrospective observational case series design, the medical records of 54 consecutive patients seen over a 6-year period at the Dean McGee Eye Institute (DMEI) with a diagnosis of adenoviral keratoconjunctivitis were analyzed retrospectively. The main outcome measure was the duration of symptomatic subepithelial corneal infiltrates following onset of acute conjunctivitis. Results: Annual case numbers ranged from 3 each in 1997 and 1998 to 26 in 2000. No more than 5 new cases presented in any single month, and no seasonal predominance was evident. The median duration of disease was 5 weeks, but the mean was 23.4 weeks, reflecting a subset of patients with a prolonged course. Indeed, 14 (25.9%) of 54 patients demonstrated symptomatic subepithelial corneal infiltrates for more than 45 days from the first examination for conjunctivitis. Conclusion: These data suggest a significant level of long-term morbidity for adenoviral keratoconjunctivitis.

Ocular surface squamous neoplasia: a standard of care survey.

Purpose: To determine the current standard of care in the treatment of ocular surface squamous neoplasia (OSSN) with particular regard to topical chemotherapeutic agents including mitomycin C, 5-fluorouracil, and interferon-α2b. Methods: A mail survey of the 325 physician members of the Ocular Microbiology and Immunology Group. Results: The survey response rate was 38%, and the average number or cases of OSSN managed by respondents was 6.5 per year. A majority (54%) believed sufficient evidence existed to justify the use of mitomycin C in the treatment of OSSN, and fewer felt the published literature justified the use of 5-fluorouracil or interferon (11% and 21%, respectively). About one-half of responding physicians always perform a biopsy before institution of topical therapy. The reported use of topical chemotherapy as an adjunct to surgical excision increased with the size of the lesion; 45% of the respondents utilize topical therapy along with surgery for lesions greater than 8 mm in diameter. Conclusion: The standard of care for the treatment of ocular surface squamous neoplasia appears to have shifted from surgery toward the use of topical chemotherapeutic agents as adjuncts to surgery or even as sole therapy, despite a paucity of long-term studies in the published literature. Longer-term observational studies and prospective masked and controlled studies are indicated to determine the optimal treatment(s) for squamous neoplasia of the ocular surface.

Corneal Cell Survival in Adenovirus Type 19 Infection Requires Phosphoinositide 3-Kinase/Akt Activation

ABSTRACT Adenovirus type 19 is a major cause of epidemic keratoconjunctivitis, the only ocular adenoviral infection associated with prolonged corneal inflammation. In this study, we investigated the role of phosphoinositide 3-kinase (PI3K) and Akt and their downstream targets in adenovirus infection, and here we report the novel finding that adenovirus type 19 utilizes the PI3K/Akt pathway to maintain corneal fibroblast viability in acute infection. We demonstrate phosphorylation of GSK-3β and nuclear translocation of the p65 subunit of NF-κB, both downstream targets of the PI3K/Akt pathway, in adenovirus-infected corneal fibroblasts in a PI3K-dependent manner. Inhibition of PI3K had no effect on early viral gene expression, suggesting normal viral internalization, but pretreatment with the PI3K inhibitor LY294002 or overexpression of dominant negative Akt induced early cytopathic effect and caspase-mediated cell death in adenovirus-infected cells. Early cell death could be circumvented despite LY294002 by overexpression of constitutively active Akt. Furthermore, we show an interaction between cSrc and the p85 regulatory subunit of PI3K in infected cells through a phosphorylation-dependent mechanism. The results presented in this paper provide the first direct evidence that PI3K-mediated Akt activation in adenovirus-infected corneal cells may contribute to viral pathogenesis by the prolongation of cell viability.

Prevalence and Risks Factors of Age-Related Macular Degeneration in Oklahoma Indians: The Vision Keepers Study

OBJECTIVE To determine the prevalence of age-related macular degeneration (AMD) and to identify its risk factors in an Oklahoma Indian population. DESIGN Cross-sectional study design. PARTICIPANTS Included 1019 Oklahoma Indians who participated in baseline and second examinations of the Strong Heart Study. METHODS Retinal photographs of at least 1 eye were obtained and graded for AMD by the University of Wisconsin Ocular Epidemiology Reading Center. Retinal photographs of 986 participants were considered gradable and were included in the study. MAIN OUTCOME MEASURES Age-related macular degeneration (early and late). RESULTS The overall prevalence of AMD in the study was 35.2%, including a prevalence of 0.81% for late AMD. The prevalence of early AMD increased from 30.6% in those aged 48 to 59 years to 46.1% in those 70 to 82 years of age. When potential risk factors were analyzed individually (univariate analyses), men with hypertension had a significantly higher prevalence of AMD (P = 0.02) than those without hypertension. In women, high-density lipoprotein cholesterol and sun exposure were associated positively with the prevalence of AMD (P = 0.01), whereas a history of using multivitamins was associated with lower AMD prevalence (P = 0.005). When multiple risk factors were analyzed simultaneously using logistic regression, only age showed significant association with AMD in both men (P = 0.02) and women (P<0.0001) and was the only significant risk factor in men. In women, multivitamin use and total cholesterol had a significant inverse association with AMD, whereas sun exposure and high-density lipoprotein cholesterol had a positive association. When men and women were combined, age and high-density lipoprotein cholesterol had significant positive associations, whereas total cholesterol, multivitamin use, and current alcohol use showed a significant inverse association with AMD. CONCLUSIONS This study was the first to report a detailed prevalence of AMD in Oklahoma Indians and its risk factors. The prevalence seemed to be relatively high compared with that in other ethnic groups. Some of the modifiable risk factors identified confirmed previous findings and can be used to design preventive programs to reduce the burden of AMD, although longitudinal data are still needed.

Dissemination of knowledge from randomized clinical trials for herpes simplex virus keratitis.

H erpes simplex virus type 1 (HSV), an enveloped virus with double-stranded DNA, is a major source of ocular infections. A 1982 study estimated that 400 000 people in the United States had ocular HSV infection, with 50 000 new and recurrent cases each year. Almost 20 years ago, the Herpetic Eye Disease Study Group was organized to elucidate the best treatments for HSV keratitis through the application of controlled, double-masked randomized clinical trials. The Herpetic Eye Disease Study trials demonstrated that topical corticosteroid with a prophylactic antiviral agent shortens the course of HSV stromal keratitis and that oral acyclovir prophylaxis significantly reduces recurrences. We surveyed eye care providers to examine the degree to which the best evidence-based practices (EBPs) in HSV keratitis have reached community care providers.

A randomized, single-blinded, prospective study that compares complications between cuffed and uncuffed nasal endotracheal tubes of different sizes and brands in pediatric patients

STUDY OBJECTIVE To compare any association between the problematic distal placement of cuffed and uncuffed nasal endotracheal tubes (NETTs) of different sizes and brands in pediatric patients. DESIGN Randomized, single-blinded, prospective study. SETTING Operating room at The Childrens Hospital. PATIENTS Pediatric patients (aged 2-18 years) scheduled for dental surgery under general anesthesia whose American Society of Anesthesiologists physical status is not greater than 2. INTERVENTION Patients were randomly assigned to preformed cuffed (1) RAE (Ring-Adair-Elwyn) endotracheal tube by Mallinckrodt or (2) nasal AGT NETT by Rüsch. MEASUREMENTS The distance between the tubes distal end and the carina was measured using a fiber optic bronchoscope. Problematic placements were defined where the tip of the tubes was within 0.5 cm of carina. MAIN RESULTS The odds of a problematic placement was 7 times higher (95% confidence interval of odds ratio, 2.06, 23.4) in patients managed with cuffed tubes than those with uncuffed tubes (P = .002). The distance between the tip of cuffed NETT tubes and carina was significantly less than with uncuffed tubes. CONCLUSIONS The chances of possible complications were significantly higher with cuffed NETT. The NETT should be kept at least 0.5 cm above carina to avoid possible complications.

Novel approach to supine positioning for infants with spinal neural tube defects

SIR—Neural tube defects (NTDs) are central nervous system birth defects originating during embryogenesis and result from failure of the neural tube closure morphogenetic process (1). NTDs can be divided into open with exposed neural tissue with cerebral spinal fluid leak, and closed with no exposed neural tissue or cerebral spinal fluid leak (2). Open NTDs often manifest as myelomeningoceles or hemimyelomeningoceles, whereas closed NTDs include meningoceles, myelocystocele, or lipomatous malformations. In the most common form, fusion fails in the caudal neural groove, resulting in lumbosacral or thoracic myelomeningocele (3). Major anesthetic concerns for patients with NTDs include positioning. In most cases, tracheal intubation can be performed in the supine position. NTDs positioning remedies among others have included: (i) towel doughnut ring supporting the uninvolved portion of the child’s back while avoiding any unnecessary NTD pressure; and (ii) placing the infant in the lateral or prone position (4,5). There is a scarcity of literature information mentioning specific devices or techniques to position infants with NTDs in the supine position. We present a novel approach to position a newborn with NTD in the supine position by uniting two polyurethane foam pillows with the triangular face cut-out placed under the NTD (Figure 1). Consent was obtained from the family. A 4-week-old, 1.8 kg, presented for placement of ventriculoperitoneal shunt under general anesthesia. Past medical history included twin gestation with caesareansection delivery at 30 weeks, myelomeningocele surgical repair on day 2 of life, ventriculomegaly, and bilateral clubbed feet. Consultation between anesthesia and neurosurgery teams occurred prior to surgery. It was imperative to limit pressure on the recent surgically corrected defect. The patient was placed in the supine position using two end-to-end polyurethane foam prone pillows, [Derma Care Adult Head Positioners (PSC Corp, Louisville, KY, USA)], with the lower triangular face cut-out placed under the myelomeningocele surgical site (Figure 1). The upper body triangle cut-out was slightly recessed for optimal head positioning, tracheal intubation, and surgical access. General anesthesia induction was achieved with sevoflurane (0–6%), fentanyl (4 lg), and cisatracurium (0.1 mg). Ventriculoperitoneal shunt placement was performed without complication. The patient was transferred to the post anesthesia care unit in the prone position. After an uneventful hospital course, the patient was discharged on postoperative day 10. Attention to detail in newborn positioning is an important consideration in pediatric neuroanesthesia. Traditional supine positioning tactics for NTDs can be cumbersome and result in suboptimal conditions. Therefore, more standardized uniform positioning devices are needed so that NTDs are protected, free of pressure, allowing the anesthesia and surgical teams optimal access. The literature has few references addressing specific positioning considerations for NTDs. Okamoto et al. described position considerations for a neonate with a large cervical myelomeningocele using cushion pads. Throughout our case, there was no fear of pressure on the myelomeningocele surgical site, or concern that the positioning device or patient would shift during VPS catheter tunneling. Lastly, foam pillows are easily modifiable, modular in nature, and allow multiple Figure 1 Two Derma Care Adult Head Positioners placed end-toend (above: in use; below: in preparation).

Failed calibration of anesthesia machine due to look-alike oxygen sensors.

Labels and medications with similar appearances have the potential to harm patients and cause delays in hospital services. We report a problem involving the Maxtec MAX-1 and MAX-11 oxygen sensors which are commonly used on anesthesia machines. These oxygen sensors have nearly identical labels which resulted in inadvertent interchanging of the sensors. The incident required the replacement of a MAX-11 sensor with a MAX-1 sensor to ensure proper functioning of the anesthesia machine. Identification of these cases can educate health care professionals of potential sources of labeling errors and safety issues and can also bring about Food and Drug Administration policy changes.

Effect of the Physician Quality Reporting Initiative on Ophthalmologists' Documentation of Practice Patterns

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