Michael Mimouni

Anxiety levels and perceived pain intensity during intravitreal injections

T he number of intravitreal antivascular endothelial growth factor (VEGF) injections has increased to a point that they are now second only to cataract surgery as the most common treatment in most tertiary ophthalmic centres across Europe and the United States (Holz et al. 2005). The pain endured during the procedure may affect their overall comfort and reduce compliance (Cintra et al. 2009) which may prove critical in diseases require recurring injections. Therefore, the purpose of this study was to evaluate the correlation between pain associated with intravitreal bevacizumab injections and the patient’s perceived anxiety level before the injection. The study and data accumulation were carried out with approval from the Meir Medical Center Institutional Review Board and adhered to the tenets of the Declaration of Helsinki. All the patients included in this prospective, consecutive, observational, non-interventional study received intravitreal bevacizumab injections at our Retina Clinic between September 2011 and March 2013. Exclusion criteria were age below 18 years and anterior segment conditions that could affect pain sensation. Patients were asked during the routine preprocedural intake to plot their anxiety level using the visual analogue scale for anxiety (VASA) on a scale from 0 to 10 with ‘no anxiety or fear’ scored as 0 and ‘unbearable anxiety or fear’ scored as 10. Immediately after receiving the injection, the subject was asked to plot their experienced level of pain during the injection using a visual analogue scale (VAS) for pain also on a scale from 0 to 10. Anaesthetic technique was uniform for all participants and included 1 ml of 2% lignocaine gel 5 min prior to injection. All injections were performed using straight injection technique with a 30-gauge needle (Knecht et al. 2009). Overall, 225 eyes of 225 patients were included in the final analysis of this study. The age of the participants was 74.26 12.72 years and 44.4% were male. In 25% (n = 56) of the participants, VASA levels were greater or equal to 6 and in 8.4% (n = 19) VAS levels greater or equal to 6. The results of the univariate correlational analyses between VAS and preprocedural parameters are depicted in Table 1. Only VASA demonstrated a significant positive correlation with VAS (R = 0.27, p = 0.005). Tables 2–4 detail the analyses of categorical preprocedural parameters and respective VAS scores. Retired patients had higher Table 1. Correlation between continuous preprocedural parameters and visual analogue scale (VAS) for pain.

Risk Factors Predicting the Need for Graft Exchange After Descemet Stripping Automated Endothelial Keratoplasty.

Purpose: To identify the risk factors predicting the need for graft exchange after Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: This is a retrospective cohort study. The study group included all 117 eyes that underwent or necessitated repeat DSAEK performed between January 2005 and June 2014 at Villa Serena–Villa Igea private hospitals (Forlì, Italy). The control group consisted of 1033 eyes that underwent only primary DSAEK during the same period. Demographic details, indications for primary surgery, ocular preoperative status and comorbidities, donor endothelial cell density (ECD), and postoperative complications were compared between the groups using univariate and multivariate analyses. Results: The prevalence of graft failure necessitating graft exchange was 10.2% (117 of 1150 eyes). In univariate analysis, a diagnosis of Fuchs endothelial dystrophy was a protective factor against the risk of repeat DSAEK. Prior trabeculectomy or aqueous shunt implantation, postoperative graft detachment, lower donor ECD, and a rejection episode were all associated with a significantly higher risk of requiring repeat DSAEK. The presence of buphthalmos, anterior chamber intraocular lens, aphakia, or prior penetrating keratoplasty were not risk factors for the failure of DSAEK. Of these variables, multivariate analysis showed that only prior aqueous shunt implantation [odds ratio (OR) = 5.5, 95% confidence interval (CI), 1.4–22.2], lower donor ECD (OR = 0.99, 95% CI, 0.997–0.999), and a documented postoperative rejection episode (OR = 18.2, 95% CI, 7.9–45.0) predicted the need for repeat DSAEK. Conclusions: DSAEK grafts have similarly good long-term survival regardless of the indication for surgery, lens status, or ocular comorbidities, with the only exception being the presence of an aqueous shunt.

Trends in Physical Medicine and Rehabilitation Publications Over the Past 16 Years

OBJECTIVES To test the hypothesis that the number of publications in the field of physical medicine and rehabilitation (PMR) has increased over the last 16 years in a linear fashion, and to compare the trends in publication between the pediatric and adult literature. DESIGN We evaluated all MEDLINE articles from January 1, 1998, to December 31, 2013, using Medical Subject Headings categories of rehabilitation. An age filter separated adult and pediatric articles. We divided articles into those with a low level of scientific evidence such as letters and editorials, and those with a high level of evidence such as controlled trials and meta-analyses. We used regression analysis to evaluate the effect of the year of publication on the number of publications of each type. SETTING Not applicable. PARTICIPANTS Not applicable. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS MEDLINE reported a total of 98,501 adult publications and 30,895 pediatric publications during the evaluated period. There was a significant linear increase in the total number of publications in adult and pediatric rehabilitation publications with multiplication factors of 3.3 and 2.9, respectively. Importantly, publications with a high level of evidence showed larger multiplication factors compared with those with a low level of evidence (5.5 and 5.1 vs 2.1 and 2.0) for the adult and pediatric literature. CONCLUSIONS The number of publications in the PMR field, especially those with a high level of scientific evidence, has increased linearly over the years, reflecting the rapid evolution of both adult and pediatric PMR.

Single cell imaging and quantification of TDP-43 and α-synuclein intercellular propagation

The intercellular spreading of protein assemblies is a major factor in the progression of neurodegenerative disorders. The quantitative study and visualization of cell-to-cell propagation using tagged-proteins is challenging due to the steric effect of relatively large fluorescence tags and the risk of ‘false positive’ identification when analyzing these rare transmission events. Here, we established a cell culture model to characterize the cell-to-cell transmission of TAR DNA-binding protein and α-synuclein, involved in amyotrophic lateral sclerosis and Parkinson’s disease, respectively, using the small nine amino acid influenza hemagglutinin tag. The novel use of single cell resolution imaging flow cytometry allowed the visualization and quantification of all individual transmission events. Cell-level analysis of these events indicated that the degree of transfer is lower than previously reported based on conventional flow cytometry. Furthermore, our analysis can exclude ‘false positive’ events of cellular overlap and extracellular debris attachment. The results were corroborated by high-resolution confocal microscopy mapping of protein localization.

The Effect of Astigmatism Axis on Visual Acuity

Purpose To evaluate the effect of astigmatism axis on uncorrected distance visual acuity (UDVA) in emmetropic eyes that underwent laser refractive surgery. Methods This retrospective study included patients who underwent laser in situ keratomileusis or photorefractive keratectomy between January 2000 and December 2015 at the Care-Vision Laser Centers, Tel Aviv, Israel. Eyes with a 3-month postoperative spherical equivalent between -0.5 D and 0.5 D were included in this study. Eyes with ocular comorbidities and planned ametropia were excluded. Study eyes were divided into 3 groups according to the steep astigmatic axis: with the rule (WTR) (60-120), oblique (31-59 or 121-149), and against the rule (ATR) (0-30 or 150-180). The UDVA of these 3 groups was compared. The oblique group was divided into oblique ATR and oblique WTR, which were compared with each other. Results A total of 17,416 consecutive eyes of 8,708 patients were studied. The WTR eyes (n = 10,651) had significantly better UDVA (logMAR 0.01 ± 0.08) than the oblique (n = 3,141, logMAR 0.02 ± 0.09) and ATR eyes (n = 3,624, logMAR 0.02 ± 0.10) (p<0.001). The oblique WTR group had significantly better UDVA than the oblique ATR group (p<0.001). The UDVA of the oblique and ATR groups was similar. Stepwise multiple regression analysis showed that the group accounted for 15% of the UDVA variance (p = 0.04). Conclusions The astigmatic axis has a small but significant effect on UDVA in emmetropic eyes; WTR was better than oblique and ATR astigmatism. Therefore, when correcting astigmatism, it may be preferable to err towards WTR astigmatism.

Treatment of adenoviral keratoconjunctivitis with a combination of povidone-iodine 1.0% and dexamethasone 0.1% drops: a clinical prospective controlled randomized study

To determine the efficacy of combination povidone‐iodine (PVP‐I) 1.0% eyedrops and dexamethasone 0.1% eyedrops in the treatment of adenoviral keratoconjunctivitis.

Cytomegalovirus retinitis in HIV-negative patients – associated conditions, clinical presentation, diagnostic methods and treatment strategy

In recent years, numerous reports have tied cytomegalovirus retinitis (CMVR) with multiple systemic conditions in the absence of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). These range from reports in apparently healthy individuals, through conditions rendering limited immune dysfunction such as advanced age and diabetes mellitus, and finally severe immune dysfunction such as in haematological and rheumatological conditions. Reports are also emerging, suggesting that induced local ocular immunosuppression is a risk factor for CMVR. We herein present a comprehensive collection of the accumulated findings regarding CMVR in non‐HIV patients. We summarize the spectrum of underlying morbidity that has been associated with CMVR, its clinical presentation, diagnostic methods and treatment choice in the attempt to suggest the optimal treatment strategy in this complicated and diverse patient population which is still currently lacking a consensus.

Corneal melting in rheumatoid arthritis patients treated with a tectonic reinforcing corneolimbal graft: an interventional case series

PurposeCorneal melting with perforation is a severe ophthalmic complication of autoimmune disorders such as rheumatoid arthritis. It requires urgent medical management in order to maintain the integrity of the globe and preserve vision. Treating this complication by penetrating keratoplasty is problematic due to the high rate of recurrence of corneal melting as well as other complications. We describe the use of a tectonic fresh-tissue corneolimbal covering graft.MethodsAn interventional case series including three patients that presented to our tertiary center between 2000 and 2015 with corneal melting and perforation, secondary to rheumatoid arthritis. Emergency surgery included suturing of a 13.00- to 13.50-mm full-thickness fresh-tissue corneolimbal covering graft to the patient’s posterior limbal zone.ResultsThe corneolimbal graft maintained the integrity of the cornea in all cases, by sealing the perforation and promoting the creation of a fibrovascular scar at the area of corneal melting. There were no complications, recurrences of host corneal melting, or perforation during the follow-up period.ConclusionFresh-tissue full-thickness corneolimbal grafts may be used to cover emergency corneal melting and perforations secondary to rheumatoid arthritis.

Peripapillary distribution of Muller cells within the retinal nerve fiber layer in human eyes

ABSTRACT The purpose of this study was to describe the distribution of Muller cell within the peripapillary retinal nerve fiber layer (RNFL) in human eyes. Eleven unpaired normal postmortem eyes were recruited into this study. Each eye was sectioned using the “umbrella technique” to obtain a concentric peripapillary ring centered on the optic disc, with a diameter of 3.0 mm. Immunohistochemistry with anti‐ CRALBP stained Muller cell within each ring. The RNFL thickness measurements around the peripapillary ring were: 262.5, 339.4, 285.4 and 347.5 &mgr;m for the temporal, superior, nasal and inferior quadrants, respectively. Muller cell were found to be unevenly distributed in the peripapillary RNFL of normal eyes. The relative Muller cell staining to the thickness of each measured segment (16.6%, 15.2%, 21.3%, and 17.9% for the temporal, superior, nasal and inferior quadrants, respectively) showed a significant increase in the nasal quadrant. The RNFL thickness measurements obtained using imaging techniques reflect the amount of axonal tissue present in this layer. In this study we highlight that around 20% of RNFL thickness is composed of non‐axonal contents which do not represent neuronal tissue, nor are they necessarily lost in the glaucomatous process. More so, the ratio of the Muller cell component to the total RNFL thickness varies around the peripapillary RNFL ring, demonstrating the lowest relative content of Muller cell superiorly and the highest content nasally. Further studies should compare the amount and distribution of Muller cell in normal versus glaucomatous eyes. HighlightsHistologically, peripapillary RNFL is thicker in the superior and inferior segments.Muller cell density is similar across all peripapillary RNFL segments.RNFL area filled by Muller cell differs significantly between segments.Neuronal to glial ratio area filled is higher in temporal and nasal segments.Different size of single Muller cell in segments explains variation.

Amblyopia and strabismus: trends in prevalence and risk factors among young adults in Israel

Aims To estimate the prevalence of amblyopia, present strabismus and amblyopia risk factors (ARFs) among young adults in Israel and to analyse trends over time of prevalence rates. Methods We conducted a cross-sectional study including 107 608 pre-enlistees aged 17.4±0.6 years born between 1971 and 1994. Across the birth years, the following trends of prevalence rates among young adults were analysed: prevalence of amblyopia, prevalence of strabismus, severity of amblyopia and prevalence of ARFs (strabismsus, anisometropia and isoametropia). Unilateral amblyopia was defined as best corrected visual acuity (BCVA) of <0.67 (6/9) in either eye or as an interocular difference of two lines or more. Bilateral amblyopia was defined as BCVA of <0.67 (6/9) in both eyes. The severity of amblyopia was classified as mild (BCVA ≥0.5 [6/12]), moderate (BCVA <0.5 [6/12] and ≥0.25 [6/24]) or severe (BCVA <0.25 [6/24]). Results The prevalence of young adulthood amblyopia declined by 33%, from 1.2% to 0.8% (R2=0.87, p<0.001) across 24 birth years. This decline may be due to a drop in unilateral amblyopia from 1% to 0.6% (R2=0.93, p<0.001), while the prevalence of bilateral amblyopia remained stable (0.2%, p=0.12). The decline in amblyopia was apparent in mild and moderate amblyopia, but not in severe amblyopia. Strabismus and anisometropia were detected in 6–12% and 11–20% of subjects with unilateral amblyopia, respectively, without significant trends. Strabismic amblyopia remained constant in the entire population across years. Isoametropia was detected in 46–59% of subjects with bilateral amblyopia without a significant trend across birth years. Prevalence of strabismus in the study population decreased by 50%, from 1.2% to 0.6% (R2=0.75, p<0.001). In subjects with present strabismus, the prevalence of mild unilateral amblyopia increased, while moderate or severe unilateral amblyopia remained relatively stable. Conclusion Among young adults, the prevalence of unilateral amblyopia, as well as the prevalence of present strabismus, decreased significantly over a period of a generation. The prevalence of strabismic, bilateral or severe (both unilateral and bilateral) amblyopia remained stable. The establishment of the national screening programme for children and the improved utility of treatment for amblyopia and strabismus coincide with these trends. Thus, it is possible that these early interventions resulted in modification of the ‘natural history’ of these conditions and their prevalence in adolescence.