Cheryl Enger

Cytomegalovirus Retinitis and Viral Resistance: Ganciclovir Resistance

Cytomegalovirus (CMV) retinitis is among the most common opportunistic infections in patients with AIDS and a substantial cause of visual loss. With long-term therapy, resistant CMV may develop. In a prospective study of 108 patients with CMV retinitis, 80.6% of patients were found to have either a positive blood culture or positive urine culture for CMV at the diagnosis of retinitis. At diagnosis of retinitis, 0.9% and 2.7% of patients had a ganciclovir-resistant blood culture isolate and urine culture isolate, respectively. Of 76 patients initially treated with ganciclovir, 11.4% had a resistant blood or urine culture isolate by 6 months of treatment and 27.5% by 9 months. The development of ganciclovir resistance during follow-up correlated with the occurrence of CMV retinitis in the contralateral eye (odds ratio = 9.06, P = .003).

The Natural Course of Central Retinal Vein Occlusion

We reviewed the records of 160 patients who had central retinal vein occlusion between 1980 and 1985. Of 168 eyes, 107 (64%) were classified as nonischemic types and 61 (36%) were classified as ischemic types. Of 107 nonischemic eyes, ten (9%) converted to the ischemic variant. Of 107 nonischemic eyes, 33 (31%) lost three or more lines of visual acuity irrespective of initial visual acuity. A final visual acuity less than or equal to 20/200 was recorded in 57 of 61 (93%) of ischemic eyes and 53 of 107 (50%) of nonischemic eyes.

Determinants of cognitive change after coronary artery bypass surgery: a multifactorial problem

BACKGROUNDnSeveral studies have investigated predictors of cognitive decline after coronary artery bypass grafting (CABG), but there is little consensus as to which specific factors are predictive of poor cognitive outcomes.nnnMETHODSnWe evaluated 127 patients undergoing CABG with standardized neuropsychological tests preoperatively, at 1 month and at 1 year. The outcome measure was a continuous variable reflecting change in z-scores for eight cognitive domains over time for individual patients. Univariate analyses were performed to evaluate the association between the demographic, operative, and postoperative factors and the cognitive outcome variables. Factors that were significant were included in a multiple linear regression analysis.nnnRESULTSnAmong the medical history variables, diabetes was associated with change in executive functions and psychomotor speed. Some of the operative variables were associated with short-term changes, but none with the 1-year outcomes. For example, the surgeons rating of degree of difficulty in selecting a cross-clamp site was associated with change in attention. Higher mean pump rate during the procedure was associated with improved performance on tests of language. The cognitive domains associated with medical variables were different from those associated with surgical variables, and the associations observed at 1-year were different from those seen at 1-month.nnnCONCLUSIONSnChange in cognition after CABG is associated with both medical and surgical variables. The specifics of these associations depend on the choice of time points after surgery. This suggests that there are multiple etiologies for these changes, with nonspecific effects of anesthesia and prolonged surgery interacting with the more specific effects of the surgical procedure itself.

The Risk for Systemic Vascular Diseases and Mortals Yin Patents with Central Retinal Vein Occlusion

In this cross-sectional study, the authors evaluated 197 patients diagnosed with central retinal vein occlusion (CRVO) at the Wilmer Ophthalmological Institute between 1980 and 1985 to determine the risk of systemic disease and mortality. Complete follow-up information for mortality was obtained in 191 (97%). National Health Interview Survey (NHIS) patients and Wilmer cataract patients formed two comparison groups. The prevalence of hypertension was significantly elevated in the CRVO cases when compared with both comparison groups (P less than 0.03, 0.005). The prevalence of diabetes mellitus was increased in CRVO cases in comparison with the NHIS group (P less than 0.005). The prevalence of cerebrovascular or cardiovascular disease was the same for all three groups, as was overall mortality. Mortality was not increased in CRVO cases as compared with United States mortality rates.

Retinal Detachment after Extracapsular Cataract Extraction with Posterior Chamber Intraocular Lens

The authors reviewed 3065 consecutive cases of extracapsular cataract extraction with posterior chamber lens implant (ECCE-PC IOL) and found the incidence of retinal detachment to be 1.4% overall (44/3065) and 1.7% in a group of eyes followed for at least 1 year (40/2330). Retrospective analysis of the retinal detachment (RD) group (n = 44) showed the patients to be significantly younger than the overall group (n = 3065) (P less than 0.0001). Comparison with an age-matched group of 302 eyes without RD showed higher rates of RD in males (P = 0.0013) and in eyes with axial eye length (AEL) greater than 25 mm (P less than 0.0001). No significant correlation was found between RD and PC IOL manufacturer, phacoemulsification (PKE), or primary discission. Sixty-four percent of RDs occurred within 1 year of cataract operation. Only 10% occurred more than 2 years later. Visual results in eyes with ultimate anatomic success of RD repair (43 of 44 eyes, averaging 15 months follow-up) are substantially better than previously reported in series with other types of IOLs (96% greater than or equal to 20/40 if the macula was not involved, 75% greater than or equal to 20/40 if the macula was involved).

Risk factors for noncompliance with glaucoma follow-up visits in a residents' eye clinic

OBJECTIVEnThis study aimed to identify factors associated with compliance with glaucoma follow-up visits.nnnDESIGNnComputer records of a university residents eye clinic were reviewed to identify a random sample of all persons who had an examination with International Classification of Disease (ICD) 9 coding (ICD9) for glaucoma suspect or glaucoma during a 2-year period (1991-1993) to undergo telephone interview.nnnPARTICIPANTSnThose who were seen at least every 6 months regardless of earlier return instructions were defined as compliant with follow-up (controls, n = 362). Those who had any lapse between visits of longer than 6 months were defined as noncompliant (cases, n = 362).nnnRESULTSnInterviews were completed for 196 cases and 242 controls. Noncompliant persons were significantly more likely to be suspects for glaucoma rather than to have definite glaucoma and to be dissatisfied with waiting time in the clinic (29.1% vs. 17.8%, P < 0.005) and to state that they did not take their glaucoma medications as prescribed (25.4% vs. 13.4%, P < 0.004). They also were less likely to have been prescribed eyedrop medication. A high percentage of both patients and controls knew that glaucoma can lead to blindness (85.2% and 88.4%, respectively). The most common reasons patients gave for not keeping follow-up visits were the perception that their eye problem was not serious enough, the cost of examinations, and that the doctor did not tell them to come back.nnnCONCLUSIONnCompliance with follow-up visits for glaucoma is associated with markers for early disease. Attempts to improve compliance might focus on improved communication of the seriousness of the disease and improvements in clinic waiting time.

Natural history of corneal astigmatism after cataract surgery

ABSTRACT Little information on the natural course of corneal astigmatism following cataract surgery exists. We report a prospective, computerized analysis of postoperative astigmatism, based on keratometry measurements, of 137 cases of extracapsular cataract extraction with intraocular lens implantation performed by one surgeon. No sutures were cut postoperatively. Surgery induced 1.44 diopters (D) of with‐the‐rule astigmatism at one month, which declined at a rate of 0.77 D and 0.35 D per month for the next two months, respectively, with a more gradual decline thereafter. The mean surgically induced astigmatism at the last postoperative visit ranged from 0.29 D at six months (minimum follow‐up) to 1.23 D at 48 months; both were against‐the‐rule. Mean follow‐up was 28.92 months. These findings may be technique specific and suggest that (1) corneal curvature continues to change slowly even two to four years postoperatively; (2) most patients develop against‐the‐rule astigmatism, thus more with‐the‐rule astigmatism is desirable in the early postoperative period; (3) selective suture removal is necessary only when significantly more than 3.00 D of surgically induced with‐the‐rule astigmatism is present.

Stereotactic radiosurgery for brain metastases: Comparison of lung carcinoma vs. non-lung tumors

In the medical literature, stereotactic radiosurgery (SRS) for brain metastases results in rates of local control of 65 to 85%. To define patient selection criteria, we measured the survival in a population with a high proportion of non-small cell lung carcinoma (NCS lung) metastases that occurred soon after primary diagnosis. Between 9/89 and 10/93 30 adults (21 M, 9 F) had SRS for metastatic NSC lung carcinoma (14 patients) vs. non-lung carcinomas (16 patients having breast (3), renal (3), melanoma (3), GI (2, thyroid (1) or carcinoma of unknown origin (4)). The metastases were solitary for 22 patients and multiple for 8 patients. Average ages (y) (± SD) were 58.6 ± 10.4 for NSC lung patients and 53.4 ± 12.5 (p=0.32) for non-lung patients. The average interval (months) from diagnosis of the primary to metastasis was 23.8 ± 41.4 for all patients. This interval was shorter for NSC lung patients: 3.1 ± 6.0 vs. 48.0 ± 51.7 (p < 0.001) for non-lung patients. Twenty seven patients had conventional radiotherapy (XRT) before (24 patients) or after (3 patients) SRS. Doses (cGy) were 3303 ± 841 for 13 NSC lung patients and 4256 ± 992 for 14 non-lung patients (p = 0.034). The median time from primary diagnosis to SRS was shorter for the NSC lung patients (11 mo) compared to the non-lung patients (35 mo). SRS was given for recurrence of metastases after XRT for 11/14 NSC lung patients and 13/16 non-lung patients. The doses (cGy) of SRS were 1579 ± 484 vs. 1682 ± 476 (p=0.45) for the NSC lung and non-lung groups, respectively. After SRS a decrease in metastasis diameter was observed in 10 of 14 NSC lung patients vs. 12 of 16 non-lung patients (p=0.85 Chi-square). Twenty-seven of the 30 patients have died. For all patients, the median survival after diagnosis of the primary and after radiosurgery was 31.3 and 8.4 months, respectively. The median survival (95% CI) from primary diagnosis was 24.3 months (13.2–27.3) for NSC lung patients and 46.5 months (39.2–65.5) for non-lung patients (p=0.005 logrank test). The median survival (95% CI) after SRS was 7.9 months (3.0–14.3) for the NSC lung patients and 8.4 (2.9–11.9) months for the non-lung patients (p=0.98 logrank test). Within the two groups, no difference in survival was observed for patients who had SRS sooner (< 1 yr for NSC lung; < 3 yr for non-lung) after primary diagnosis: 9.3 vs. 6.5 mo for NSC lung (p = 0.21) and 10.5 vs. 7.2 mo for non-lung (p=0.87). In this series, the shortened intervals from primary diagnosis to SRS for NSC lung metastases was associated with post-SRS survivorship that was equivalent to the more favorable non-lung group.

T Cell Subsets and Cytomegalovirus Retinitis in Human Immunodeficiency Virus-Infected Patients

A case-control study was done to investigate the relationship between T cell subsets and cytomegalovirus (CMV) retinitis in human immunodeficiency virus (HIV)-infected subjects with or without CMV retinitis and CD4+ cell counts of <0.050 x 10(9)/L. Cell surface markers on peripheral blood lymphocytes were evaluated using flow cytometry. Patients with CMV retinitis had significantly lower levels of CD8+ cells (median: 0.152 x 10(9)/L) compared with levels for controls (median: 0.296 x 10(9)/L, P < .001). Significant down-regulation of costimulatory molecule CD28+ and lymphocyte function-associated antigen-1 (LFA-1) expression was observed in patients versus controls (CD28+: 0.048 x 10(9)/L vs. 0.143 x 10(9)/L, P < .001; LFA-1: 0.238 x 10(9)/L vs. 0.400 x 10(9)/L, P < .001), but no significant differences were noted for NK cells. We propose that progressive loss of the CD3+ CD8+ cell subset and down-regulation of CD28 and LFA-1 accessory molecules are associated with an increased risk of CMV retinitis in HIV-infected patients.

Cytomegalovirus retinitis and viral resistance: 3. Culture results

PURPOSEnTo evaluate the relationship between blood and urine cultures for cytomegalovirus and clinical outcomes in patients with cytomegalovirus retinitis.nnnMETHODSnProspective epidemiologic study of 108 patients with newly diagnosed cytomegalovirus retinitis. Blood and urine were cultured for cytomegalovirus at diagnosis of retinitis, at 1 month and 3 months after diagnosis, and every 3 months thereafter.nnnRESULTSnOf the patients, 80.6% were found to have either a positive blood culture or urine culture for cytomegalovirus at the time of diagnosis of retinitis, and a positive blood culture at diagnosis was associated with an increased mortality (odds ratio = 1.91, P = .012). Follow-up cultures were positive in approximately 20% of patients, and the rate was constant over time. The development of a positive blood or urine culture during follow-up correlated with the occurrence of cytomegalovirus retinitis in the contralateral eye in those patients with unilateral disease at diagnosis (odds ratio = 5.74, P = .001).nnnCONCLUSIONSnPatients with cytomegalovirus retinitis and positive blood cultures for cytomegalovirus have a poorer prognosis.