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Purpose To describe the use of glycerine in improving media clarity in cases with edematous cornea. Methods Retrospective case-series including patients with posterior segment pathologies needing surgical invention and having corneal edema. Each case was studied for the role of topical application of glycerine instead of viscoelastic agents and the course of surgery. The cases were followed up for minimum 3-months duration. Results Six cases with corneal edema having posterior segment pathology underwent surgery with intraoperative topical application of glycerine. The corneal edema was seen to clear with progression of surgery and was maintained until the end of surgery. Procedures like vitreoretinal surgery, identification of break, internal limiting membrane peeling, intraocular lens explantation, scleral indentation, DSEK graft removal, and subretinal band removal could be performed in these cases. Conclusion Intraoperative glycerine use during vitreoretinal surgeries is helpful in improving the corneal clarity and maintaining it till the end of surgery.

Purpose To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer. Patient A 19-year-old male presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus exam showed inferior vitreous hemorrhage, retinal whitening, and pre-, intra-, and sub-retinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and post-septal orbital emphysema. Two months following injury, vitreous and retinal hemorrhages and macular hole resolved. Five months following injury, visual acuity improved to 20/20. Discussion Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. While this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.

Purpose To describe with multimodal imaging including the use of ultra-widefield optical coherence tomography (OCT) imaging a distinct phenotype of autosomal recessive nanophthalmos associated with a novel mutation of the MFRP gene (membrane-type frizzled-related protein). Methods Case report and review of the relevant literature. Patients Single patient followed by the Weill Cornell Medicine Department of Ophthalmology Retina and Glaucoma Services. Results A patient with a novel homozygous mutation in the MFRP gene (c.472C>T) presented with nanophthalmos, optic disc drusen, foveal hypoplasia, and extensive peripheral retinoschisis, which was revealed to be multilevel retinoschisis on ultra-wide field OCT. Unlike other reported cases, the findings associated with this novel mutation did not include foveoschisis nor clinically obvious retinitis pigmentosa. The patient underwent prophylactic peripheral laser iridotomy in both eyes. Conclusion Here we present a patient with nanophthalmos, optic disc drusen, and foveal hypoplasia associated with extensive peripheral retinoschisis imaged by ultra-widefield OCT, but not foveal retinoschisis or prominent retinitis pigmentosa. The findings may expand the clinical spectrum of MFRP-associated nanophthalmos.

BACKGROUND/PURPOSE To describe the association between autosomal dominant Best disease and peripapillary angioid streak-like changes. METHODS Case report of two siblings. RESULTS A 76-year-old Caucasian male was referred for evaluation of bilateral macular changes and worsening visual distortion over the preceding 2 years. Best corrected visual acuity (BCVA) measured 20/30 in the right eye and 20/80 in the left eye. Funduscopic examination revealed multifocal yellow lesions in the posterior pole that were hyper-autofluorescent on short-wavelength excitation and corresponded with subretinal hyperreflective material on optical coherence tomography. The posterior pole examination was interesting due to the juxtapapillary involvement of the vitelliform lesions as well as the presence of bilateral peripapillary angioid streak-like changes despite no history of conditions associated with angioid streaks. On further workup, an electro-oculogram revealed reduced Arden ratios and a known heterozygous missense mutation in BEST1 (c.903T>G; p.D301E) was found. The patient's 69-year-old younger brother was brought in and found to have a remarkably similar phenotype, including the presence of angioid streak-like changes associated with the same BEST1 mutation. CONCLUSIONS These two cases demonstrate the possibility of late-onset multifocal vitelliform disease due to dominantly inherited BEST1. A consistent phenotype in this family with macular lesions extending into the peripapillary region, associated with angioid streak-like changes, suggests susceptibility of this region to changes in dominant BEST1-vitelliform macular dystrophy.

PURPOSE To present a new technique to treat refractory retinal detachment secondary to optic disc pit. METHODS An interventional case report. RESULTS A 25-year-old man with congenital optic disc pit had two failed vitrectomies involving laser around the optic disc, internal limiting membrane peel and flap to plug the disc pit, and gas tamponade to reattach the retina. With all options running out, a further vitrectomy with autologous retinal transplant and silicone oil tamponade was carried out to treat the refractory serous retinal detachment; the silicone oil was removed at 6 weeks after the last procedure. The retina remained successfully attached at 6 months post-surgery with the patient maintaining his baseline visual acuity. CONCLUSION The use of autologous retinal transplant is a new approach to treat refractory retinal detachment secondary to congenital optic disc anomalies, and adds to our options of dealing with this complex condition when first-line approaches have failed.

Purpose To describe central serous chorioretinopathy (CSCR) cases presenting as uveal effusion syndrome, providing new insights into "pachychoroid spectrum" diseases. Methods Clinical charts, color fundus photographs, fluorescein angiography, indocyanine green angiography, optical coherence tomography, ultrasound imaging, cerebral magnetic resonance imaging and biometry of four eyes of three patients were assessed. A literature review was conducted. Results The three patients had peripheral choroidal detachment and inferior bullous retinal detachment associated with CSCR features detected using multimodal imaging, including fluorescein and indocyanine green angiography. The choroid was thick in the three patients, and uveal effusion occurred after steroid treatment in all cases. Subretinal fluid drainage and deep sclerectomy with flaps of 4x4 mm in both inferior quadrants were performed in 3 eyes of 2 patients with good outcomes. One patient was treated with photodynamic therapy. All three patients developed a typical leopard-spot pigmentary pattern in the fundus. Conclusion A severe presentation of highly exudative CSCR may occur in rare cases with a peripheral choroidal detachment mimicking uveal effusion syndrome. These severe cases highlighted the role of choroidal thickening and hyperpermeability, choroidal vein dilation and possible scleral thickening in both entities.

Szivak, TK, Thomas, MM, Pietrzak, RH, Nguyen, DR, Ryan, DM, and Mazure, CM. Obesity Risk Among West Point Graduates Later in Life. J Strength Cond Res XX(X): 000-000, 2020-The purpose of this investigation was to evaluate sex differences in health and fitness outcomes among United States Military Academy (USMA) graduates (class years 1980-2011). Subjects (n = 701 men, 641 women, age: 45.7 ± 9.3 years) were surveyed as a part of a larger investigation on risk and resiliency factors among USMA graduates. Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ) short form and calculation of weekly metabolic equivalents (METs). Overweight and obesity status were assessed by body mass index (BMI). Significance for the study was set at p ≤ 0.05. Obesity rates for men (30.1%) were significantly higher than for women (16.6%). Men reported significantly higher (p = 0.01) vigorous METs·wk (1,214.6 ± 1,171.6) than women (1,046.8 ± 1,133.2) despite significantly higher (p = 0.00) BMI values (28.75 ± 4.53 kg·m) than women (25.90 ± 5.48 kg·m). Women were 89% more likely to have ever been on a diet and reported higher (15.2%) Army Body Composition Program enrollment rates than men (6.3%). Obesity rates among men reflect trends seen in the broader military, Veteran, and U.S. adult populations, whereas obesity rates among women were lower. Men may be at a greater risk for obesity later in life despite higher self-reported physical activity; however, lean body mass and self-report bias should be considered. Because lifetime obesity may be influenced by factors other than physical activity, health initiatives should use a comprehensive approach early in the career of military officers.

Gills, JL, Spliker, B, Glenn, JM, Szymanski, D, Romer, B, Lu, H-C, and Gray, M. Acute citrulline-malate supplementation increases total work in short lower-body isokinetic tasks for recreationally active females during menstruation. J Strength Cond Res XX(X): 000-000, 2021-Citrulline-Malate (CM) exhibits acute ergogenic benefits through nitric oxide production (NO) and augmentation of vasodilatory properties. Nitric oxide is upregulated by estrogen and may influence CM's ergogenic efficacy in women. Therefore, the objective of this study was to evaluate the acute effects of CM supplementation on lower-body isokinetic performance in recreationally active women. Nineteen women (23.5 ± 3.1 years; 164.8 ± 7.0 cm; 61.9 ± 27.4 kg; 28.8 ± 8.1% body fat) completed 2 randomized, double-blind, crossover trials consuming CM (8 g CM + 12 g dextrose) or placebo (12 g dextrose). For testing trials, subjects were in the menstruating portion of the follicular phase of their menstrual cycle. Subjects performed a 5-repetition isokinetic leg extension protocol (5RP) followed by a 50-repetition isokinetic leg extension protocol (50RP), 60 minutes after supplement consumption. Repeated measures analysis of variance analysis showed that CM significantly increased total work completed, relative total work, and total work during maximum repetition compared with placebo (p < 0.05); but no significant performance differences existed between trials for peak torque production (p = 0.14) for the 5RP. No significant differences were identified between trials for peak torque production (p = 0.69) or total work (p = 0.33) completed during the 50RP. CM increased total work completed during the 5RP, but provided no ergogenic benefit during the 50RP in recreationally active menstruating women. Citrulline-Malate amplifies power-based resistance exercise performance in women during the follicular phase of the menstrual cycle, potentially because of depressed estrogen levels. Additional research is needed to identify timing efficacy of CM to increase sport performance during each phase of the menstrual cycle.

Gäbler, M, Prieske, O, Elferink-Gemser, MT, Hortobágyi, T, Warnke, T, and Granacher, U. Measures of physical fitness improve prediction of kayak and canoe sprint performance in young kayakers and canoeists. J Strength Cond Res XX(X): 000-000, 2021-Markers of talent selection and predictors of performance in canoe and kayak sprint are not yet well defined. We aimed to determine the combination of variables (i.e., demographic, anthropometric, and physical fitness) that most accurately predicts sprint performance (i.e., 500- and 2000-m race time) in semielite, young kayakers and canoeists (n = 39, age 13 year, 10F). The level of significance was set at p < 0.05. Linear regression analyses identified boat type (i.e., kayak or canoe), skeletal muscle mass, and average power during a 2-minute bench pull test, normalized to body mass, as predictors of 2000-m race time (R22000 m = 0.69, Akaike information criterion [AIC] = 425) and together with vertical jump height, as predictors of 500-m race time (R2500 m = 0.87, AIC = 255). This was an improvement over models containing solely demographic variables (R2500 m = 0.66, AIC = 293; R22000 m = 0.44, AIC = 446) and over models containing demographic and anthropometric variables (R2500m = 0.79, AIC = 277; R22000 m = 0.56, AIC = 437). Race time showed the strongest semipartial correlations with the 2-minute bench pull test (0.7 ≤ r ≤ 0.9). Adding physical fitness data (i.e., 2-minute bench pull test) to demographic and anthropometric data improves the prediction accuracy of race times in young kayak and canoe athletes. The characteristics of physical fitness tests should resemble as much as possible the biomechanical (e.g., prime movers) and metabolic (e.g., duration) demands of the sport.

We evaluated a protocolized endoscopic necrosectomy approach with a lumen-apposing metal stent (LAMS) in patients with large symptomatic walled-off pancreatic necrosis (WON) comprising significant necrotic content, with or without infection.Randomized trials have shown similar efficacy of endoscopic treatment compared to surgery for infected WON.We conducted a regulatory, prospective, multicenter single-arm clinical trial examining the efficacy and safety of endoscopic ultrasound (EUS)-guided LAMS with protocolized necrosectomy to treat symptomatic WON ≥ 6 cm in diameter with 30% solid necrosis. After LAMS placement, protocolized WON assessment was conducted and endoscopic necrosectomy was performed for insufficient WON size reduction and persistent symptoms. Patients with radiographic WON resolution to ≤ 3 cm and/or 60-day LAMS indwell had LAMS removal, then 6-month follow-up. Primary endpoints were probability of radiographic resolution by 60 days and procedure-related serious adverse events (SAEs).Forty consecutive patients were enrolled September 2018 - March 2020, of whom 27 (67.5%) were inpatients and 19 (47.5%) had clinical evidence of infection at their index procedure. Mean WON size was 15.0 ± 5.6 cm with mean 53.2% ± 16.7% solid necrosis. Radiographic WON resolution was seen in 97.5% (95% CI, 86.8%, 99.9%) by 60 days, without recurrence in 34 patients with 6-month follow-up data. Mean time to radiographic WON resolution was 34.1 ± 16.8 days. SAEs occurred in 3 patients (7.5%), including sepsis, vancomycin-resistant enterococcal bacteremia and shock, and upper gastrointestinal bleeding. There were no procedure-related deaths.EUS-guided drainage with protocolized endoscopic necrosectomy to treat large symptomatic or infected walled-off necrotic pancreatic collections was highly effective and safe. Clinicaltrials.gov no: NCT03525808.

Exertional heat stroke (EHS) is a true medical emergency with potential for organ injury and death. This consensus statement emphasizes that optimal exertional heat illness management is promoted by a synchronized chain of survival that promotes rapid recognition and management, as well as communication between care teams. Health care providers should be confident in the definitions, etiologies, and nuances of exertional heat exhaustion, exertional heat injury, and EHS. Identifying the athlete with suspected EHS early in the course, stopping activity (body heat generation), and providing rapid total body cooling are essential for survival, and like any critical life-threatening situation (cardiac arrest, brain stroke, sepsis), time is tissue. Recovery from EHS is variable, and outcomes are likely related to the duration of severe hyperthermia. Most exertional heat illnesses can be prevented with the recognition and modification of well-described risk factors ideally addressed through leadership, policy, and on-site health care.

Objective This study aimed to analyze our outcomes of primary premaxillary ostectomy and setback combined with lip adhesion as the first stage in repair of the bilateral cleft lip with fly-away premaxilla. Methods This retrospective study included all patients who required primary premaxillary setback by a single surgeon to achieve successful lip repair between 2011 and 2017 at a tertiary children's hospital. All patients had bilateral cleft lip and complete cleft palate with significant premaxillary protrusion. All patients either had failed presurgical orthodontic manipulation or were thought to be poor candidates because of the rigidity of the premaxilla on clinical examination. Patient data were obtained from review of medical records and photographs. Surgical technique is described. Results Eleven patients with bilateral cleft lip, all of whom also had complete cleft palate, underwent primary premaxillary setback and lip adhesion at an average age of 8.2 months. The mean follow-up was 1.9 years (range, 139 days to 4.5 years). All patients subsequently completed formal lip repair, of which 10 have undergone palatoplasty. Serial photography documented stable premaxillary position and successful lip repair within the follow-up time frame. No patient had postoperative premaxillary instability or vascular compromise. One patient had dehiscence of the lip adhesion requiring reoperation. Conclusions Primary premaxillary ostectomy and setback allows for successful staged formal lip repair in patients with bilateral cleft lip and palate who have failed presurgical infant orthopedics. Further research is required regarding long-term follow-up with respect to midfacial growth.

Purpose To report a case of Stickler type IV with familial exudative vitreoretinopathy (FEVR) phenotype. Material and methods Retrospective case report. Results A 24-year-old female presented with right eye exotropia and decreased vision. She had no facial or typical retinal features of Stickler syndrome, but complained of right-sided hearing loss and right-sided neck pain. Examination of the right eye showed a chronic combined exudative and traction retinal detachment (E-TRD) with temporal retinal dragging associated with far temporal retinal exudations and fibrovascular proliferations. The left eye had an attached retina with large areas of peripheral temporal retinal non-perfusion on fluorescein angiography, sharply demarcated by end circulation vascular pruning and mild peripheral vascular leakage, consistent with familial exudative vitreoretinopathy (FEVR) phenotype. Genetic analysis identified two heterozygous c.1052C>A and c.1349A>G variants in COL9A1, but did not disclose any mutation in genes classically associated with FEVR. Conclusion FEVR-like retinal vascular features can be the presenting sign in patients with Stickler syndrome type IV.

Purpose To describe two cases of catastrophic, bilateral retinal vascular occlusion following intravitreal (IVT) bevacizumab injection. Methods Case series. Main outcome measures included clinical and fluorescein angiography (FA) findings. Results Case 1 - A 65-year-old woman with calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasis (CREST) syndrome developed acute, severe, bilateral visual loss two weeks following bilateral IVT bevacizumab injection for proliferative diabetic retinopathy. Examination and FA revealed moderate anterior chamber inflammation, bilateral perivascular retinal hemorrhages and near total retinal vascular occlusion. Extensive testing revealed moderately elevated anti-B2 glycoprotein (antiphospholipid) antibodies. Case 2 - An 85-year-old man with polymyalgia rheumatica and left eye exudative age-related macular degeneration experienced severe, bilateral, sequential visual loss in the left then right eye approximately three weeks following IVT bevacizumab left eye injection. Examination revealed bilateral panuveitis, diffuse perivascular exudates, and intraretinal hemorrhages. FA showed diffuse venous leakage. Extensive testing revealed an elevated anti-nuclear antibody and mildly elevated anti-cardiolipin antibody. Conclusion Patients with underlying retinal vascular vulnerabilities may be at increased risk of catastrophic, bilateral retinal vascular occlusion following treatment with IVT bevacizumab. The moderate to severe intraocular inflammation in both cases, and the contralateral involvement following unilateral IVT injection in Case 2, suggest a possible delayed immune-mediated mechanism.

To describe a novel optical coherence tomography (OCT) finding in a case of macular serous retinal detachment (SRD) after pars plana vitrectomy (PPV) and panretinal photocoagulation (PRP).Retrospective case report.A 52-year-old Hispanic male presented with dense vitreous hemorrhage secondary to proliferative diabetic retinopathy in his right eye, for which PPV with endolaser was performed.His post-operative course was complicated by significantly decreased vision and a macular SRD that was characterized on OCT by a reticular network of hyperreflective bands in the subretinal space. Fluid and hyperreflective material in the subretinal space resolved by post-operative week (POW) 6 with standard post-operative eye drops. However, persistent ellipsoid zone disruption was seen up to POW 20.Extensive subretinal bands can be seen after PRP. This novel finding can pose diagnostic and management challenges, but may resolve with conservative medical management.

Purpose To present novel findings in stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR), including the largest series of optical coherence tomography angiography (OCT-A) findings to date. Methods A retrospective case series with multimodal imaging was obtained and reviewed. Results All three patients were women, ages 59-63. Two cases were unilateral and one was bilateral. Vision ranged from 20/20 to 20/60 in the affected eyes. Peripheral retinoschisis was observed in all three patients. All patients were followed for a minimum of one year. In one case, progressive macular retinoschisis leading to foveal involvement was observed over two years, with an associated vision decline from 20/25 to 20/60. Attempted interventions included topical dorzolamide in all cases and intravitreal bevacizumab in one patient; however, no treatment effect was observed. Foveal avascular zone (FAZ) size was within normal limits (mean 280[micro]m). In all SNIFR eyes, the retinoschisis cavities were nonvascular. Conclusion Novel findings regarding SNIFR include the progressive nature of foveal involvement and the lack of response to topical dorzolamide and intravitreal bevacizumab. FAZ was normal in all eyes, consistent with the relatively preserved vision in these cases. Retinoschisis cavities were nonvascular in all eyes, a finding which may give insight into the mechanism of this disease.

Purpose To report the case of a patient presenting with newly diagnosed atypical hemolytic uremic syndrome (aHUS) and Purtscher-like retinopathy. Methods Observational case report and review of literature. Patient A 38-year-old female presented with 3 months of rashes, fevers, arthralgias, and abdominal pain. Initial workup was suggestive of hypereosinophilic syndrome or adult-onset Still's disease. The patient developed acute renal failure and progressively blurry vision bilaterally over the course of 5 days. Funduscopic exam was notable for numerous Purtscher flecken and cotton-wool spots, with rare intraretinal hemorrhages at the posterior pole. The constellation of renal failure, hemolytic anemia, and thrombocytopenia prompted a work-up for thrombotic microangiopathy that was remarkable for a mutation in the gene coding for complement protein C9. Results The patient was diagnosed with aHUS. The patient was treated with intravenous pulse dose steroids for 3 days and an extended course of eculizumab. The patient's renal failure resolved, and her visual acuity improved, though she had residual visual field constriction and developed bilateral optic atrophy. Outcomes of other cases of Purtscher-like retinopathy related to aHUS are reviewed. Conclusion Purtscher-like retinopathy is a rare, but severe ophthalmic complication of aHUS. Eculizumab is an effective treatment for the systemic illness caused by aHUS, and anatomic resolution of Purtscher-like retinopathy may follow, although visual prognosis remains guarded. Recovery of visual acuity may lag behind resolution of macular edema in these patients.

Purpose To describe an unusual case of unilateral, endogenous endophthalmitis in an otherwise healthy, term neonate. Methods A 3-week-old otherwise healthy, term male infant was referred to St. Louis Children's Hospital for a second opinion of presumed panuveitis of the right eye. Patients Single male infant. Results Diffusion weighted magnetic resonance imaging (MRI) demonstrating purulent intraocular contents facilitated the diagnosis of endophthalmitis. Examination of surgical vitreous samples by staining and cytology demonstrated Gram-positive bacterial cocci in short chains, thereby confirming endophthalmitis. Polymerase chain reaction testing of vitreous fluid identified Streptococcus agalactiae, despite an unremarkable systemic workup and a negative pre-partum maternal Group B streptococcal screen. Conclusions Endogenous endophthalmitis is a rare but devastating cause of vision loss in otherwise healthy, term neonates. Prompt diagnosis may be facilitated by MRI imaging and diagnostic vitreous biopsy.

Chen, CH, Chiu, CH, Tseng, WC, Wu, CY, Su, HH, Chang, CK, and Ye, X. Acute effects of combining dynamic stretching and vibration foam rolling warm-up on lower-limb muscle performance and functions in female handball players. J Strength Cond Res XX(X): 000-000, 2021-The purpose of this study was to compare the acute effects of 3 warm-up protocols on knee flexor and extensor muscles performance in elite female collegiate handball players. Ten female handball players with poor hamstring flexibility completed 3 randomly sequenced experimental visits. During each visit, a different warm-up protocol (general running warm-up [GW], dynamic stretching [DS], or DS combined with vibration foam rolling [DS + VR]) was delivered before the subsequent tests: quadriceps and hamstring muscle stiffness, knee extension and flexion range of motion (ROM), knee joint position sense, knee extension and flexion isokinetic strength with hamstring-quadriceps strength ratio, and muscle endurance during fatiguing exercise. Relative to the GW, the DS + VR protocol resulted in significantly greater knee flexion ROM (mean ± SD: DS + VR = 79.4° ± 7.7°; GW = 69.3° ± 9.6°) and lower hamstring muscle stiffness (DS + VR = 253.33 ± 36.20 N·m-1; GW = 292.89 ± 24.28 N·m-1). In addition, the DS + VR protocol also yielded greater hamstring muscle endurance than the other 2 protocols did (fatigue percentage: DS + VR = 30.24% ± 10.84%; GW = 41.40% ± 8.98%; DS = 42.22% ± 9.42%). Therefore, the results of this experiment suggest that it can be more beneficial for the female handball players to warm-up with the DS + VR, rather than the GW and DS protocols.

Objectives: The objective of this study is to assess quality of the most popular cholesteatoma videos on YouTube using recognized scoring systems and to determine if video quality metrics correlated with video popularity based on likes and views Design: Cross sectional survey of available data Setting: Metadata acquisition using YouTube searches using Australian IP addresses Participants: Three independent neuro-otologists partaking in scoring videos Main outcome measures: Each video was viewed and scored by three independent assessors using both a novel tool to score the usefulness of the video as well as the validated DISCERN scoring tool. Popularity metrics were analyzed and compared to video popularity. Results: A total of 90 YouTube videos were analyzed with an average 55,292 views per video with an average of 271 likes and 22 dislikes. The inter-rater correlation was moderate with Fleiss-kappa score 0.42 [P < 0.01] using a novel scoring tool for cholesteatoma and inter-rater correlation coefficient was 0.78 [95% CI = 0.58 - 0.90] indicating good reliability for DISCERN scores. The overall video quality was poor with higher DISCERN scores found in videos uploaded from Academic Institutions. Conclusions: Informative video quality on YouTube on cholesteatoma is overall of poor quality. Videos with unclassified sources or more dislikes correlated poorly with video quality. Given the increase in patients turning to the internet for information regarding their health conditions, otology and otolaryngology societies should be encouraged to publish high quality YouTube videos on cholesteatoma and other ear conditions.

192 Background: Sleep disturbance negatively impacts quality of life and recovery. Our objective was to evaluate the relationship between individual patient factors (demographic, surgical, pain, opioid use, and psychosocial factors) and greater sleep disturbance. Methods: In this prospective longitudinal study, patients completed validated measures regarding their sleep disturbance, pain, opioid use, and psychological symptoms preoperatively and then 2 weeks, 6 and 12 months postoperatively. Objective pain sensitivity measures were evaluated at baseline using quantitative sensory testing. Univariable and multivariable generalized estimating equations (GEE) evaluated demographic, surgical, pain, and psychological predictors of sleep disturbance during the first year after surgery for breast cancer. Results: Female patients (n = 259) reported varying degrees of sleep disturbance, which were longitudinally associated with pain, psychosocial factors such as anxiety, depression, and affect. While the mean degree of sleep disturbance did not change substantially over time, the link to pain severity appeared to strengthen over the first postoperative year. Independent preoperative predictors of worse sleep disturbance on multivariable longitudinal GEE included younger age (B = -.09, p =.006), opioid use (B = 3.09, p =.02), higher pain (B =.19, p =

Objective To identify risk factors for tumor positive resection margins after neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal cancer. Summary background data Esophagectomy after nCRT is associated with tumor positive resection margins in 4-9% of patients. This study evaluates potential risk factors for positive resection margins after nCRT followed by esophagectomy. Methods All patients who underwent an elective esophagectomy following nCRT in 2011-2017 in the Netherlands were included. A multivariable logistic regression was performed to assess the association between potential risk factors and tumor positive resection margins. Results In total, 3900 patients were included. Tumor positive resection margins were observed in 150 (4%) patients. Risk factors for tumor positive resection margins included tumor length (in centimeters, OR:1.1, 95% CI: 1.0-1.1), cT4-stage (OR:3.0, 95% CI: 1.2 - 6.7) and an Ivor Lewis esophagectomy (OR:1.6, 95% CI: 1.0 - 2.6). Predictors associated with a lower risk of tumor positive resection margins were; squamous cell carcinoma (OR:0.4, 95% CI: 0.2 - 0.7), distal tumors (OR:0.5, 95% CI: 0.3 - 1.0), minimally invasive surgery (OR:0.6, 95% CI: 0.4 - 0.9) and a hospital volume of >60 esophagectomies per year (OR:0.6, 95%CI: 0.4 - 1.0). Conclusions In this nationwide cohort study, tumor and surgical related factors (tumor length, histology, cT-stage, tumor location, surgical procedure, surgical approach, hospital volume) were identified as risk factors for tumor positive resection margins after nCRT for esophageal cancer. These results can be used to improve the radical resection rate by careful selection of patients and surgical approach and are a plea for centralization of esophageal cancer care.

Objective This study aims to examine the indications, techniques and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the Wiper Blade Manoeuvre (WBM) for transcystic intrahepatic choledochoscopy. Summary background data Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particulary with the increasing role of transcystic exploration. Methods The indications, techniques and operative and postoperative data on choledeochoscopy collected prospectively during 1320 transcystic and choledochotomy explorations were analysed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochocoscopes. Results Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilised more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. 20 retained stones (2.1%) were encountered but no choledochoscopy related complications. Conclusions Choledochoscopy should always be performed during a choledochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilised in over 50% of explorations, increasing their rate of success. When attempted, the transcystic Wiper Blade Manoeuvre achieves intrahepatic access in 70-80%. It should be part of the training curriculum.

Objective To understand the effectiveness of Rescue Improvement Conference, a forum that addresses failure to rescue (FTR). Summary background data Every year over 150,000 patients die after elective surgery in the United States. FTR is the phenomenon whereby delayed recognition and/or response to serious surgical complications leads to a progressive cascade of adverse events culminating in death. Rescue Improvement Conference is an adapted version of the Ottawa-style M&M conference, designed to address common contributors to FTR: ineffective communication and inadequate problem solving. Methods Mixed methods data were used to evaluate Rescue Improvement Conference, a bi- monthly forum that was first introduced in our academic medical center in 2018. Conference effectiveness data were collected via survey and open-text responses after five conferences between September 2018 and February 2020. We focused on five indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and actionable opportunities for improvement. Twelve surgical faculty and house staff also provided feedback during semi- structured interviews. Qualitative data were analyzed using thematic analysis. Results Conference attendees (N = 140) felt that Rescue Improvement Conference was effective-all five indicators had mean scores above five on Likert scales. The qualitative data supports the quantitative findings, and three additional themes emerged: Rescue Improvement Conference enables the representation of diverse voices, promotes interdisciplinary collaboration, and encourages multilevel problem solving. Conclusions Rescue Improvement Conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications by providing stakeholders a forum to identify and discuss factors that contribute to FTR.

Background: The long-term outcomes following surgical resection for pancreatic ductal adenocarcinoma (PDAC) remains poor, with only 20% of patients surviving 5 years after pancreatectomy. Patient selection for surgery remains sub-optimal largely due to the absence of consideration of aggressive tumor biology. Objective: The aim of this study was to evaluate traditional staging criteria for PDAC in the setting of molecular subtypes. Methods: Clinicopathological data were obtained for 5 independent cohorts of consecutive unselected patients, totaling n = 1298, including n = 442 that underwent molecular subtyping. The main outcome measure was disease-specific survival following surgical resection for PDAC stratified according to the American Joint Commission for Cancer (TNM) staging criteria, margin status, and molecular subtype. Results: TNM staging criteria and margin status confers prognostic value only in tumors with classical pancreatic subtype. Patients with tumors that are of squamous subtype, have a poor outcome irrespective of favorable traditional pathological staging [hazard ratio (HR) 1.54, 95% confidence interval (CI) 1.04–2.28, P = 0.032]. Margin status has no impact on survival in the squamous subtype (16.0 vs 12.1 months, P = 0.374). There were no differences in molecular subtype or gene expression of tumors with positive resection margin status. Conclusions: Aggressive tumor biology as measured by molecular subtype predicts poor outcome following pancreatectomy for PDAC and should be utilized to inform patient selection for surgery.

OBJECTIVE To investigate the effectiveness of a circulating tumor cell (CTC)-based classifier in stratifying stage IB lung adenocarcinoma (LUAD). SUMMARY BACKGROUND DATA Stage IB LUADs have an approximately 70% 5-year survival rate. The clinical application of adjuvant chemotherapy (ACT) is controversial due to inconsistent results in a series of trials and few useful guide biomarkers. Thus, there is a pressing need for robust biomarkers to stratify stage IB patients to define which group would most likely benefit from ACT. METHODS 212 stage IB LUAD patients were enrolled and were divided into three independent cohorts. The aptamer-modified NanoVelcro system was used to enrich the CTCs. RESULTS A cutoff of < 4 or ≥ 4 CTCs as the optimal prognostic threshold for stage IB LUAD was generated to stratify the patients in a 70-patient cohort into low-risk and high-risk groups. Patients with ≥ 4 CTCs in the training cohort had shorter progression-free survival (PFS, P < 0.0001) and overall survival (OS, P < 0.0001) than patients with < 4 CTCs. CTC number remained the strongest predictor of PFS and OS even in a multivariate analysis including other clinicopathological parameters. Furthermore, a nomogram based on the CTC count was developed to predict the 3-year and 5-year survival in the training cohort and performed well in the other two validation cohorts (C-index: 0.862, 0.853 and 0.877). CONCLUSION The presence of ≥ 4 CTCs can define a high-risk subgroup, providing a new strategy to make optimal clinical decisions for stage IB LUAD.

OBJECTIVE To compare the reoperation rate for recurrence between different mesh types in laparoscopic ventral hernia repair. SUMMARY BACKGROUND DATA Ventral hernia repair has improved over the last decades. Nevertheless, recurrence rates are still high, and one type of mesh was recently found to increase it even more. METHODS A nationwide cohort study based on prospectively collected data from the Danish Ventral Hernia Database. We included adult patients that had undergone a laparoscopic ventral hernia repair for either an incisional or a primary hernia. The primary and incisional hernias were analyzed in separate cohorts. The mesh-group with the lowest reoperation for recurrence curve was used as the reference. The outcome was reoperation for recurrence. RESULTS Study population comprised 2,874 patients with primary hernias and 2,726 with incisional hernias. For primary hernias, Physiomesh (HR = 3.45 (2.16-5.51)) and Proceed Surgical Mesh (HR = 2.53 (1.35-4.75)) had a significantly higher risk of reoperation for recurrence than DynaMesh-IPOM. For incisional hernias, Physiomesh (HR = 3.90 (1.80-8.46), Ventralex Hernia Patch (HR = 2.99 (1.13-7.93), Parietex Composite (incl. Optimized) (HR = 2.55 (1.17-5.55), and Proceed Surgical Mesh (HR = 2.63 (1.11-6.20)) all had a significantly higher risk of reoperation for recurrence than Ventralight ST Mesh. CONCLUSION For primary hernias, Physiomesh and Proceed Surgical Mesh had a significantly higher risk of reoperation for recurrence compared with DynaMesh-IPOM. For incisional hernias, the risk was significantly higher for Physiomesh, Parietex Composite, Ventralex Hernia Patch, and Proceed Surgical Mesh compared with Ventralight ST Mesh. This indicates that type of mesh may be associated with outcomes, and mesh choice could therefore depend on hernia type.

Objective To assess the initial clinical experience with a novel endograft system (NEXUS Aortic Arch Stent Graft System) designed to treat aortic arch pathologies and address the morphology and hemodynamic challenges of the aortic arch. Summary background data The aortic arch remains the most challenging part of the aorta for both open and endovascular repair. Transcatheter aortic arch repair has the potential to significantly reduce surgical risks. Methods Patients underwent transcatheter aortic arch repair with a single branch, two stent graft system, implanted over a through-and-through guidewire from the brachiocephalic trunk, to the descending aorta with an ascending aorta stent graft. The ascending aorta stent graft is deployed into a designated docking sleeve to connect the two stent grafts and isolate the aortic arch pathology. Proximal landing zone in all cases was in Zone 0. Anatomical inclusion criteria included adequate landing zone in the ascending aorta, brachiocephalic trunk and descending thoracic aorta. Preparatory debranching procedure was performed in all patients with carotid - carotid crossover bypass and left carotid to left subclavian bypass, or parallel graft from descending aorta to left subclavian artery. Safety and performance were evaluated through one year. Survival analysis used the Kaplan-Meier method. Results Twenty-eight patients, 79% males, with a mean age of 72.2 ± 6.2 years were treated with 100% procedural success. Isolated aortic arch aneurysm was the principle pathology in 17 (60.7%) of patients while chronic aortic dissection was the principle pathology in 6 (21.4%) of patients. The remaining 5(17.8%) had combined or other pathologies. At one month, the vascular pathology was excluded in 25 of 26 alive patients (96.1%). The 30 days mortality rate was 7.1%, stroke rate was 3.6% (all non-disabling) and combined mortality/stroke rate was 10.7%. One year mortality was 10.7%, without device or aneurysm related death. Two patients (7.1%) reported stroke or transient ischemic attack at one year that recovered completely. One year combined mortality/stroke rate was 17.8%. There were three patients (10.7%) that had device related unplanned reinterventions through one year. Conclusions The NEXUS Aortic Arch Stent Graft System, a novel single branch, two stent graft system used for endovascular aortic arch repair that requires landing in the ascending aorta, demonstrates a high success rate with excellent one year safety and performance.

Objective: To develop a core outcome set (COS), an agreed minimum set of outcomes to measure and report in all studies evaluating the introduction and evaluation of novel surgical techniques.Summary Background Data: Agreement on the key outcomes to measure and report for safe and efficient surgical innovation is lacking, hindering transparency and risking patient harm.Methods: (I) Generation of a list of outcome domains from published innovation-specific literature, policy/regulatory body documents, and surgeon interviews; (II) Prioritization of identified outcome domains using an international, multi-stakeholder Delphi survey; (III) Consensus meeting to agree the final COS. Participants were international stakeholders, including patients/public, surgeons, device manufacturers, regulators, trialists, methodologists and journal editors.Results: 7,972 verbatim outcomes were identified, categorized into 32 domains, and formatted into survey items/questions. 410 international participants (220 professionals, 190 patients/public) completed at least one round 1 survey item, of which 153 (69.5%) professionals and 116 (61.1%) patients completed at least one round 2 item. 12 outcomes were scored ‘consensus in’ (‘very important’ by ≥70% of patients and professionals) and 20 ‘no consensus’. A consensus meeting, involving 19 professionals and 10 patient/public representatives, led to agreement on a final 8-domain COS. Six domains are specific to a surgical innovation context: modifications, unexpected disadvantages, device problems, technical procedure success, whether the overall desired effect was achieved, surgeons’/operators’ experience. Two domains relate to intended benefits and expected disadvantages.Conclusions: The COS is recommended for use in all studies prior to definitive RCT evaluation to promote safe, transparent, and efficient surgical innovation.

OBJECTIVE To clarify whether systemic lymph node dissection (LND) influences the safety of surgery and the survival of patients with locally advanced esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (nCRT). SUMMARY BACKGROUND DATA Prognostic impact of systemic lymphadenectomy during surgery after nCRT for ESCC is still uncertain and requires clarification. METHODS This is a secondary analysis of NEOCRTEC5010 trial which compared nCRT followed by surgery versus surgery alone for locally advanced ESCC. Relationship between number of LND and perioperative, recurrence and survival outcomes were analyzed in the nCRT group. RESULTS Three-year overall survival was significantly better in the nCRT group than the S group (75.2% vs 61.5%; P=0.011). In the nCRT group, greater number of LND was associated with significantly better overall survival (HR, 0.358; P < 0.001) and disease-free survival (HR, 0.415; P=0.001), but without any negative impact on postoperative complications. Less LND (< 20 vs ≥ 20) was significantly associated with increased local recurrence (18.8% vs 5.2%, P=0.004) and total recurrence rates (41.2% vs 25.8%, P=0.027). Compared to patients with persistent nodal disease, significantly better survival was seen in patients with complete response and with LND ≥ 20, but not in those with LND < 20. CONCLUSIONS Systemic lymph node dissection does not increase surgical risks after nCRT in ESCC patients. And it is associated with better survival and local disease control. Therefore, systemic lymphadenectomy should still be considered as an integrated part of surgery after nCRT for ESCC.

OBJECTIVE To determine late results of AS-DD procedure in long-segment (LSBE) and extralong-segment BE (ELSBE) using subjective and objective measurements to ascertain the histological impact over intestinal metaplasia (IM) and progression to EAC. SUMMARY OF BACKGROUND DATA Barrett esophagus (BE) is a known precursor of esophageal adenocarcinoma (EAC), and Nissen fundoplication has proven to be unable to stop mixed reflux among them. Our group proposed a surgical procedure that handles pathophysiological changes responsible for BE. METHODS This prospective study included 127 LSBE and ELSBE subjects submitted to clinical and functional analyses. They were presented to selective vagotomy, fundoplication, partial gastrectomy with Roux-en-Y reconstruction. The changes in IM were determined in both groups. RESULTS Follow-up was completed at a mean of 18 years in 81% of the cases. Visick I-II scores were seen in 88% of LSBE and 65% in ELSBE (P < 0.01). There was significant healing of erosive esophagitis and esophageal peptic ulcers, and strictures were resolved in 71%. There was 38% of IM regression in LSBE. Two cases in each group progressed to EAC at a mean of 15 years. Pathologic acid reflux was abolished in 91% and duodenal in 100%. There was a regression of low-grade dysplasia to IM in 80%. CONCLUSIONS AS-DD permanently eliminates pathologic refluxate to the esophagus. The progression to HGD/EAC is lower compared to medical treatment, with an 8-fold reduction in LSBE and 2.2-fold in ELSBE. AS-DD seems to influence IM behaviors, and it is a tool that could reduce and delay progression to EAC.

BACKGROUND Quality leaders are concerned that creation of multi-hospital health systems may lead to surgeons traveling to and from distant hospitals and thus to more fragmented surgical care and worse outcomes for their patients. Despite this concern, little empirical data exist on outcomes of multi-site vs. single-site surgeons. METHODS Using national Medicare data, we assessed trends in the number of multi-site vs. single-site surgeons from 2011 to 2016. We performed a multivariable regression analysis to compare overall 30-day mortality differences, stratified by system and rural status, and examined trends over time. RESULTS The number of multi-site surgeons and the percentage of multi-site surgeons per hospital decreased over time (24.2% to 19.0%; 44.3% to 41.8%). Overall, multi-site surgeons had lower 30-day mortality than single-site surgeons (2.24% vs. 2.50%, p < 0.01). When stratified by system status, multi-site surgeons performed better in-system (2.47% vs. 2.58%, p < 0.01); by rural status, multi-site surgeons had lower mortality in non-rural hospitals (2.42% vs. 2.51%, p < 0.01). The statistically significant but small mortality advantage of multi-site vs. single-site surgeons decreased over time, such that by 2016 there was no difference in outcomes between multi-site and single-site surgeons. CONCLUSION For the majority of study years, multi-site surgeons had lower 30-day mortality than single-site surgeons, but this trend narrowed until outcomes were equivalent by 2016. Surgeons operating at multiple hospitals can provide surgical care to patients without any evidence of increased mortality.

OBJECTIVE The aim of this study was to investigate whether our previously reported improvements in short-term cancer esophagectomy outcomes after large-scale regionalization in the U.S. translated to longer-term survival benefit. BACKGROUND Regionalization is associated with better early postoperative outcomes following cancer esophagectomy; however, data regarding its effect on long-term survival is mixed. METHODS We retrospectively reviewed 461 patients undergoing cancer esophagectomy before (2009-2013, N = 272) and after (2014-2016, N = 189) regionalization. Kaplan-Meier curves and χ2 tests were used to describe 1- and 3-year survival in each era. Hierarchical logistic regression models examined the adjusted effect of regionalization on mortality. RESULTS Compared to pre-regionalization patients, post-regionalization patients had significantly higher 1-year survival (83.1% versus 73.9%, p = 0.02) but not 3-year survival (52.9% versus 58.2%, p = 0.26).Subgroup analysis by cancer stage revealed that 1-year survival benefit was only significant among mid-stage (IIB-IIIB) patients, whereas differences in 3-year survival only approached significance among early-stage (IA-IIA) patients.In multivariable analysis, only regionalization was a predictor of lower mortality at 1 year (OR 0.54, 95%CI:0.29,1.00), and only thoracic specialty at 3 years (OR 0.62, 95%CI:0.38,0.99). Older age, more advanced stage, and complications were associated with higher 1- and 3-year mortality. Comorbidity, minimally invasive approach, surgeon volume, facility volume, and neoadjuvant treatment were not significant in this model. CONCLUSIONS Regionalization was associated with improved 1-year survival after cancer esophagectomy, independent of factors such as morbidity or volume in our adjusted models. This survival benefit did not persist at 3 years, likely due to the aggressive nature of the disease.

Objective To conduct a population-level analysis of temporal trends and risk factors for high symptom burden in patients receiving surgery for non-small-cell lung cancer (NSCLC). Summary background data A population-level overview of symptoms after curative intent surgery is necessary to inform decision making and supportive care for patients with lung cancer. Methods Retrospective cohort study of patients receiving surgery for stage I-III NSCLC between January 2007-September 2018. Prospectively collection Edmonton Symptom Assessment System (ESAS) scores, linked to provincial administrative data, were used to describe the prevalence, trajectory and predictors of moderate-to-severe symptoms in the year following surgery. Results A total of 5,350 patients, with 28,490 unique ESAS assessments, were included in the analysis. Moderate-to-severe tiredness (68%), poor wellbeing (63%) and shortness of breath (60%) were the most common symptoms reported. The rise and fall in the proportion of patients experiencing moderate-to-severe symptoms after surgery coincided with the median time to first (58 days, IQR: 47-72) and last cycle of chemotherapy (140 days, IQR: 118-168), respectively. There was eventual stabilization, albeit above the pre-operative baseline, within 6-7 months after surgery. Female sex (RR 1.09-1.26), lower income (RR 1.08-1.23), stage III disease (RR 1.15-1.43), adjuvant therapy (RR 1.09-1.42), chemotherapy within two weeks of an ESAS assessment (RR 1.14-1.73), and pneumonectomy (RR 1.05-1.15) were associated with moderate-to-severe symptoms following surgery. Conclusions Knowledge of population-level prevalence, trajectory and predictors of moderate-to-severe symptoms after surgery for NSCLC can be used to facilitate shared decision making and improve symptom management throughout the course of illness.

Patients with opioid use disorder (OUD) seek care in primary care settings where nurses support the provision of medication-assisted treatment. Office-based opioid treatment (OBOT) that includes buprenorphine hydrochloride administration under the supervision of a nurse for stabilization and maintenance therapy has the potential to improve outcomes for patients with OUD in primary care settings. However, the first step is to determine if OBOT nurses provide nurse-sensitive care, which consists of activities that have been shown to make a difference in patient outcomes. Content analysis of 368 nursing notes from 100 patients enrolled in an OBOT program in an urban hospital-based primary care clinic was conducted. Data were analyzed descriptively according to quantity and qualitatively according to the content. Entries indicative of care coordination and transition management were extracted. Seven content categories within care coordination were identified, including harm reduction, medication management, symptom management, communication between providers, promoting adherence, self-management goal setting, and patient education. Four areas within transition management were identified including supporting connections to resources, referrals for care, medication reconciliation, and communication with other facilities. Care coordination was documented more frequently than transition management. The presence of nurse-sensitive indicators provides evidence for and distinguishes the role of the nurse in OUD care.

Purpose To describe a case of bilateral cystoid macular edema in a patient with long-standing Tramadol hydrochloride use. Methods Observational case report. Results and discussion: A 73-year-old female patient was referred for progressive, bilateral decreased visual acuity. The patient was phakic with a best-corrected visual acuity (BCVA) at presentation was 20/50 on the right eye (RE) and 20/64 on the left eye (LE). The patient had a history of low back pain and had been on Tramadol hydrochloride 200 mg/day for 16 years. Bilateral cystoid macular edema (CME) was confirmed by means of multimodal imaging, including OCT angiography. Tramadol intake was progressively reduced over one month and then completely interrupted. At three months follow-up, the cystoid macular edema had completely resolved and BCVA improved in both eyes. Conclusion CME may be associated with longstanding treatment with Tramadol hydrochloride. Tramadol hydrochloride associated CME is described, as well as its resolution on Tramadol cessation.

Purpose To report a case of syphilitic outer retinopathy revealed after progression to panuveitis following a course of oral steroids for suspected poison ivy. Methods Retrospective case report. Results A 44-year-old diabetic man presented with progressive symptoms of nyctalopia and color vision changes associated with outer retinal disruption on macular imaging but minimal evidence of intraocular inflammation on examination. A short-course of oral steroids for an unrelated skin condition induced rapid progression to frank panuveitis with retinal vascular sheathing and retinal whitening. Systemic work-up identified syphilis as the etiology. The patient's visual symptoms and disruption of the photoreceptor and retinal pigment epithelial layers on OCT improved after treatment with intravenous penicillin. Conclusion Syphilitic outer retinopathy (SOR) represents an unusual manifestation of ocular syphilis that can present with minimal exam findings. We present here a case of oral steroid use resulting in progression of SOR to a more fulminant form of syphilitic uveitis which ultimately revealed the correct diagnosis and prompted the correct intervention. This case highlights the importance of maintaining a high level of suspicion for this treatable condition.

Traumatic optic neuropathy can have varying presentations. Blunt focal trauma can lead to optic nerve avulsion with underlying retinal findings. A case of partial optic nerve avulsion after finger poke injury leading to focal retinal ischemia is reported.Visual acuity, fundus photography with fluorescein angiography, and spectral-domain optical coherence tomography were performed to document the findings in a 16-year-old man who presented after a finger poke injury to the left orbit during a water polo match.On initial presentation, examination revealed decreased visual acuity with a fixed left pupil and afferent pupillary defect by reverse. On slit-lamp examination of the left eye, a hyphema was present. Dilated fundus examination revealed layering vitreous hemorrhage over the posterior pole and an avulsed vitreous base. On follow-up, a gap temporal to the optic nerve head consistent with a partial optic nerve avulsion was noted once the vitreous hemorrhage cleared. Multimodal imaging revealed retinal ischemia temporal to the disc on fluorescein angiography with corresponding changes in the inner retinal layers and retinal nerve fiber layer using spectral-domain optical coherence tomography.Clinicians should have a high suspicion for optic nerve avulsion if a patient presents with new vitreous hemorrhage and afferent pupillary defect after a finger-poke injury. Optic nerve avulsion injury can cause retinal ischemia, likely because of interruption of retinal blood flow as a result of nerve shearing injury. Multimodal imaging can reveal focal retinal injury and aid in proper diagnosis and follow-up.

PURPOSE To report a case of paracentral acute middle maculopathy (PAMM) in an otherwise healthy young, multiparous woman in her second trimester of pregnancy. METHODS Case report RESULTS:: A 38-year-old woman in her twentieth week of pregnancy presented with a four-day history of an acute paracentral scotoma in her left eye. Fundoscopic examination of the left eye was significant for a white-gray lesion inferonasal to the fovea which corresponded with spectral domain-optical coherence tomography (SD-OCT) hyperreflectivity at the outer plexiform layer-inner nuclear layer junction and optical coherence tomography angiography (OCTA) non-perfusion. A diagnosis of paracentral acute middle maculopathy was made. The patient was sent for a hypercoagulability work-up that revealed elevated factor VIII activity, which has been associated with increased risk of complications during pregnancy. CONCLUSION PAMM in pregnancy may be secondary to an underlying hypercoaguable condition. We recommend systemic evaluation and referral to a high-risk pregnancy specialist if PAMM is diagnosed during pregnancy. Additionally, OCTA in PAMM may demonstrate reperfusion of the affected vessels.