Michael Kinori

Time trends in the incidence and causes of blindness in Israel.

PURPOSE To evaluate time trends in the incidence and causes of new cases of blindness in Israel between 1999 and 2008. DESIGN Descriptive, retrospective population-based study. METHODS During the decade of the study, 19 862 inhabitants of Israel were newly registered as legally blind. Data were retrieved from the 1999 to 2008 annual reports of the National Registry of the Blind in Israel and were reviewed retrospectively. Specific rates by age, gender, calendar year, and cause of blindness were calculated. Total and cause-specific annual age-standardized rates were calculated as well. Findings were evaluated by the use of Poisson regression models. RESULTS The age-standardized rate of incidence of newly registered legal blindness at the end of the studied decade was half of that at the beginning, declining from 33.8 per 100 000 in 1999 to 16.6 per 100 000 in 2008. The decline mainly was attributable to a decreased incidence of blindness resulting from age-related macular degeneration, glaucoma, diabetic retinopathy, and cataract. CONCLUSIONS Contemporary interventions in ophthalmology combined with widely available universal free access to healthcare seem to be effective in causing a major reduction in the incidence of blindness.

Takotsubo cardiomyopathy and QT interval prolongation: who are the patients at risk for torsades de pointes? ☆

OBJECTIVES QT interval prolongation is prevalent among patients with Takotsubo cardiomyopathy (TC), whereas torsades de pointes (TdP) has rarely been reported in these patients. We studied all peer-reviewed reports on TC-associated QT interval prolongation and all peer-reviewed reports on TC-associated TdP to characterize the clinical circumstances leading to TdP in patients with TC. METHODS The literature search yielded 14 reports on TC-associated TdP and 26 reports on TC-associated QT interval prolongation. Overall, 15 patients with TC-associated TdP and 86 patients with TC-associated QT interval prolongation were reported. We systematically reviewed each report and recorded the risk factors for TdP as well as the clinical circumstances of TC. RESULTS The prevalence of the male sex was higher among patients with TC-associated TdP relative to patients with TC-associated QT interval prolongation (26.7% vs 5.8%; P = .01). There was a trend in the mean maximal corrected QT interval being longer among patients with TC-associated TdP relative to patients with TC-associated QT interval prolongation (679.9 +/- 230.6 vs 555.9 +/- 63.8 milliseconds; P = .06). There were no differences between patients with TC-associated TdP and patients with TC-associated QT interval prolongation in mean age, maximal troponin levels, and lowest ejection fraction. Overall, 12 (80.0%) patients with TC-associated TdP had risk factors for TdP other than the female sex and systolic dysfunction, including suspicion of congenital long QT syndrome, bradycardia, hypokalemia, recent conversion from atrial fibrillation to sinus rhythm, and using QT prolonging agents. CONCLUSIONS Men with TC-associated QT interval prolongation are at risk for TdP. Most patients with TC-associated TdP have risk factors for TdP other than the female sex and systolic dysfunction.

Comparison of Pars Plana Vitrectomy With and Without Scleral Buckle for the Repair of Primary Rhegmatogenous Retinal Detachment

PURPOSE To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD). DESIGN Retrospective, nonrandomized, interventional case series. METHODS We reviewed 181 consecutive cases of vitrectomy for primary RRD at 2 major medical centers in Israel. The follow-up was at least 3 months. There were 96 eyes in the PPV group and 85 eyes in the PPV plus SB group. Main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA). RESULTS SSAS was achieved in 81.3% and 87.1% in the PPV and PPV plus SB groups, respectively (P=.29). Final anatomic success rate was 98.9% and 98.8%, respectively (P=.61). Final VA was 0.41 (20/51) in the PPV group and 0.53 (20/68) in the PPV plus SB group (P=.13). The final VA was significantly better than the preoperative VA in both groups (P<.0001). In detachments caused by inferior tears, SSAS rates were 80.9% and 81.5% in the PPV and PPV plus SB groups, respectively (P=.74). In phakic eyes, SSAS rates were 92% and 87.5%, respectively, and in pseudophakic eyes, SSAS rates were 77.5% and 86.7%, respectively, in the PPV and PPV plus SB groups (P=.29). CONCLUSIONS The reattachment rate and the final VA were similar in both groups. The addition of SB did not improve the results and was associated with slightly lower VA than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD, addition of a SB is not warranted.

Calcitonin gene‐related peptide (CGRP) may award relative protection from interferon‐γ‐induced collapse of human hair follicle immune privilege

Abstract:  Interferon‐γ (IFNγ)‐induced collapse of hair follicle (HF) immune privilege (IP) is a key element in the pathogenesis of alopecia areata. In this pilot study, we investigated whether the immunosuppressive neuropeptide, calcitonin gene‐related peptide (CGRP), can protect from and/or restore IFNγ‐induced HF‐IP collapse. After showing that human scalp HFs express CGRP receptor‐like receptor (CRLR) immunoreactivity, anagen HFs were cultured in the presence of IFNγ, with CGRP added before or after. Adding CGRP after IFNγ administration (‘restoration assay’) failed to downregulate IFNγ‐induced ectopic MHC class I expression, while MHC class II expression was reduced. However, administering CGRP before IFNγ application (‘protection assay’) significantly reduced the IFNγ‐induced overexpression and ectopic expression of MHC class I and II and reduced the increased degranulation of perifollicular mast cells induced by IFNγ. This suggests that CGRP may not restore HF‐IP once it has collapsed, but may protect it from collapsing. Therefore, CRLR stimulation might help to retard AA progression.

Vitrectomy for Idiopathic Epiretinal Membrane in Elderly Patients: Surgical Outcomes and Visual Prognosis

Purpose: To evaluate the clinical course and visual prognosis of elderly patients over 75 years of age who underwent PPV and peeling of idiopathic ERM. Design: Retrospective case series. Methods: A retrospective chart review of patients that underwent vitrectomy for idiopathic ERM in two public hospitals. Twenty nine eyes of 29 patients 75 years and older who underwent PPV and ERM peeling were included in the study series. Patients with additional ocular vision-limiting conditions other than cataract were excluded. Main outcome measures included VA improvement, OCT changes and complications. Results: Mean patient age was 79.6 years, the highest in published literature. Mean change in VA was 0.23 logMAR units, and 65.5% patients gained 2 or more lines of vision. Eight of the 10 patients aged 80 years or older gained 2 lines or more. Fourteen patients (48.3%) achieved final VA of 20/40 or better, and only 2 (6.9%) had final VA of 20/200 or worse. Concurrent cataract extraction was performed in 73% of the phakic eyes, and at the end of the follow up 93% were pseudophakic. Complication rates were similar to those reported in the literature. Conclusions: Pars plana vitrectomy with ERM peeling is safe and effective in restoring VA in elderly patients, and the results are comparable to those previously reported for younger patients with idiopathic ERM. Old age should not hinder surgery in patients with idiopathic ERM who seek to improve their vision and quality of life.

Increased erythrocyte aggregation in men with coronary artery disease and erectile dysfunction

We studied the association between erythrocyte aggregation (EA) and erectile dysfunction (ED) in men with coronary artery disease (CAD). Men with CAD documented by coronary angiography filled the Sexual Health Inventory for Males questionnaire to detect ED and assess its severity. EA was evaluated by filming slides of blood smear. Low percentage of slide field covered by erythrocytes represented increased EA. Overall, 133 men with CAD, mean ages 62.4±12.2 years, were included: 100 (75.2%) with ED and 33 (24.8%) without ED. EA was increased among men with ED compared with men without ED (percentage of slide field covered by erythrocytes 66.7±14.7 vs 73.1±14.5%; P=0.03). After adjustment for age, diabetes mellitus, hemoglobin and hematocrit levels, EA was associated with ED severity (r=0.18; P=0.038). We conclude that EA is increased in men with CAD and ED. This finding may be relevant to the pathophysiology of ED in men with CAD.

Pneumatic Retinopexy for the Repair of Primary Rhegmatogenous Retinal Detachment A 10-Year Retrospective Analysis

OBJECTIVE To assess the outcome and risk factors for failure of pneumatic retinopexy (PR) in eyes with primary rhegmatogenous retinal detachment (RRD). METHODS Data of patients who underwent PR for the repair of primary RRD, from January 1, 2000, through June 30, 2011, were retrieved from medical records and retrospectively analyzed. Patients with a follow-up time of less than 4 months were contacted and invited for examination. Patients with less than 2 months of follow-up were excluded. Successful cases (attached retina at 2 months after the PR) were compared with failures. A subgroup analysis was performed comparing successful and failed cases of RRD that were reattached with only 1 additional operation. RESULTS Two hundred seventy-six eyes (271 patients) underwent PR during the study period, of which 258 eyes (93.5%) were included in the study. Mean (SD) follow-up time was 36.1 (39.4) months; only 23 eyes (8.9%) had a follow-up of less than 4 months. Successful reattachment at 2 months was achieved in 171 eyes (66.3%). Sixty-seven eyes (77.0% of the failed cases) were reattached with only 1 additional operation and final anatomical success was achieved in 256 eyes (99.2%). Successful cases had significantly better final vision (P= .002) and fewer postoperative complications (P ≤ .026). However, nonsignificant differences were found between the primary failure PR cases that underwent only 1 additional operation and the successful cases (P ≥ .073). CONCLUSIONS Pneumatic retinopexy is a good surgical option for primary RRD. Most cases of primary failure are reattached with 1 additional procedure and have excellent final vision.

Can the Hair Follicle Become a Model for Studying Selected Aspects of Human Ocular Immune Privilege

Immune privilege (IP) is important in maintaining ocular health. Understanding the mechanism underlying this dynamic state would assist in treating inflammatory eye diseases. Despite substantial progress in defining eye IP mechanisms, because of the scarcity of human ocular tissue for research purposes, most of what we know about ocular IP is based on rodent models (of unclear relevance to human eye immunology) and on cultured human eye-derived cells that cannot faithfully mirror the complex cell-tissue interactions that underlie normal human ocular IP in situ. Therefore, accessible, instructive, and clinically relevant human in vitro models are needed for exploring the general principles of why and how IP collapses under clinically relevant experimental conditions and how it can be protected or even restored therapeutically. Among the few human IP sites, the easily accessible and abundantly available hair follicle (HF) may offer one such surrogate model. There are excellent human HF organ culture systems for the study of HF IP in situ that instructively complement in vivo autoimmunity research in the human system. In this article, we delineate that the human eye and HF, despite their obvious differences, share key molecular and cellular mechanisms for maintaining IP. We argue that, therefore, human scalp HFs can provide an unconventional, but highly instructive, accessible, easily manipulated, and clinically relevant preclinical model for selected aspects of ocular IP. This essay is an attempt to encourage professional eye researchers to turn their attention, with appropriate caveats, to this candidate surrogate model for ocular IP in the human system.

Retained lens fragments: nucleus fragments are associated with worse prognosis than cortex or epinucleus fragments

Purpose. To identify factors that determined the outcome of eyes that underwent pars plana vitrectomy for retained lens fragments after phacoemulsification. Methods. A retrospective review of the records of 63 eyes that underwent vitrectomy for retained lens fragments after phacoemulsification. Fragments were defined as nuclear if they contained any nucleus component or non-nuclear if they contained only cortex and epinucleus. Nuclear fragments were further divided into large (at least 1/3 the size of the nucleus) or small. Results. A total of 67% of eyes had retained nuclear fragments and 33% had non-nuclear fragments. Of the eyes with nuclear fragments, 64% had large fragments and 36% had small fragments. Statistical analysis revealed that the lens fragment type was the major determinant of the final visual acuity (VA). Only 38.8% (14/36) of the eyes with nuclear fragments achieved final VA of 20/40 or better, compared with 77.7% (14/18) of eyes with non-nuclear fragments (p=0.007). All other parameters, including size of the nuclear fragment, were not correlated with final VA. The major complications encountered in this series were retinal detachment (12.6%), Pseudophakic bullous keratopathy (6.3%), cystoid macular edema (15.8%), and glaucoma (15.8%). Conclusions. The major finding of our study is that posterior dislocation of nuclear lens fragments is associated with worse visual outcome than that of non-nuclear fragments. This may be related to a more complicated course of the cataract surgery, direct mechanical damage to the retina, a stronger inflammatory response, or a more traumatic vitrectomy procedure.

Gold Micro-Shunt Implants Versus Ahmed Glaucoma Valve: Long-term Outcomes of a Prospective Randomized Clinical Trial.

Purpose:To compare long-term outcomes of Ahmed glaucoma valve (AGV), 24 &mgr;m Gold Micro-Shunt (GMS), and 48 &mgr;m GMS implantation for treatment of refractory glaucoma. Patients and Methods:This was a 3-armed randomized interventional prospective clinical trial. Within an institutional setting, 29 adults (29 eyes) with refractory glaucoma [mean baseline intraocular pressure (IOP) ≥22 mm Hg on maximal medication, status post at least 1 failed trabeculectomy, defined visual field defect, and without recent glaucoma-related surgery] were randomly assigned to AGV, 24 &mgr;m GMS, or 48 &mgr;m GMS implantation. Exclusion criteria included uveitic, traumatic, or neovascular glaucoma. The 3 groups were comparatively evaluated preoperatively and 1, 2, 3, and 5 years postoperatively for IOP and numbers of glaucoma medications needed. Main outcome measures were implant survival rates. Results of the 24 and 48 &mgr;m GMS groups were also compared separately. Results:In all groups the final IOP (in mm Hg) was significantly lower than the preoperative IOP (17.3±2.6 vs. 33.5±6.7, P=0.004; 17.8±2.4 vs. 25.7±0.7, P=0.0001; and 19.6±5.2 vs. 35.6±2.2, P=0.0001 in the AGV, 24 &mgr;m GMS, and 48 &mgr;m GMS groups, respectively). Differences between initial and final mean numbers of medications were not significant. Cumulative probabilities of success at 5 years were 77.8%, 77.8%, and 72.7%, respectively. Conclusions:During long-term follow-up, success rates in the 2 GMS groups and the AGV group were similar. Likewise, IOP reduction and the need for continued glaucoma medical therapy remained high and were similar for all devices.