Search

PURPOSE To compare the rotational stability of 2 commonly used toric presbyopia-correcting (PC) intraocular lenses (IOLs) and their monofocal toric counterparts. SETTING Single 2-surgeon private practice. DESIGN Retrospective study. METHODS This study included 2 cohorts: (1) all eyes receiving a toric ReSTOR (n = 61 eyes, 49 patients) or toric Symfony (n = 779 eyes, 520 patients) IOL from September 2016 to January 2019; and (2) all eyes receiving an AcrySof (n = 2 393) or TECNIS (n = 731) monofocal toric IOL (TIOL) from April 2015 to January 2019. Eyes were only excluded if digital marking could not be used. All patients had image-guided digital marking to verify TIOL position at the conclusion of surgery. Postoperative rotation was determined by dilated examination performed later on the day of surgery or the following morning. RESULTS The toric ReSTOR IOL was more likely to rotate 5 degrees or less than the toric Symfony IOL, 91.8% vs 79.0% (P = .01). This remained true for rotation of 10 degrees or less (100% vs 89.5%, P < 0.003). The mean rotation was 2.3 degrees for toric ReSTOR IOL compared with 4.5 for toric Symfony IOL (P = .01). Statistically significantly more eyes with toric Symfony IOL required a return to the operating room for repositioning (6.9% vs 0%, P < .03). More TECNIS monofocal TIOL eyes required surgical repositioning than AcrySof monofocal TIOL eyes (3.5% vs 1.2%, P < .001). CONCLUSIONS Between these PC-TIOLs, the Symfony IOL was more likely to rotate and to require surgical repositioning than the ReSTOR IOL. The TECNIS TIOL built on the same platform as the Symfony IOL was more likely to require surgical repositioning than that by the AcrySof TIOL. Despite comparable rotational stability between the Symfony and TECNIS monofocal TIOLs, the Symfony was twice as likely to require surgical repositioning.

Objective To evaluate the role of apparent diffusion coefficient (ADC) in differentiating radiation necrosis (RN) from recurrent tumor after Gamma Knife radiosurgery (GKRS) for brain metastases (BMs). Methods Forty-one patients with BM who underwent surgical intervention after GKRS at Cleveland Clinic (2006–2017) were included in this retrospective study. The ADC values of the growing lesions and the contralateral hemisphere were calculated using picture archiving and communication system. These values were correlated to the percentage of RN identified on pathologic evaluation of the surgical specimen. Results The median age of the patients was 59 years (range, 25–86 years), and lung cancer (63.4%) was the most common malignancy. Median initial (pre-GKRS) target volume of the lesions was 5.4 cc (range, 0.135–45.6 cc), and median GKRS dose was 18.0 Gy. Surgical resection or biopsy was performed at a median of 176 days after GKRS. Two variables were statistically significant predictors of predominate RN (75%–100%) in the surgical specimen: 1) ADC of the lesion on the preresection magnetic resonance imaging (MRI) and 2) initial pre-GKRS target volume. ADC >1.5 × 10−3 mm2/s within the lesion on MRI predicted significant RN on pathologic evaluation of the lesion (P 10 cc), the risk of identifying significant necrosis in the pathologic specimen was elevated (P Conclusions Our data suggest that the combination of lesion ADC on MRI prior to surgical intervention and the initial target volume can predict RN with reasonable accuracy.

OBJECTIVEIatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors’ aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine.METHODSAll patients older than 18 years who underwent lumbar PSOs at the authors’ institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson’s Disease Questionnaire–39 (PDQ-39) and Patient Health Questionnaire–9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined.RESULTSA total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively).CONCLUSIONSIn this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

The use of intraoperative multimodal monitoring (IOM) in spinal deformity surgeries is well documented. In particular, pedicle subtraction osteotomy (PSO), a corrective procedure for sagittal deformity of the spine, often involves IOM usage. By providing immediate feedback to the operating surgeon, IOM has the potential to eliminate or at least minimize the risk of iatrogenic neurological injury. However, despite the widespread usage of IOM, there is currently no standardization of IOM usage in complex spine surgeries, including lumbar PSOs, and decisions concerning IOM utilization are often driven by surgeon experience and preference. This creates a state of clinical equipoise, which is further complicated by the varying degrees of benefit that IOM has on patient outcomes depending on the operation and spinal levels involved. For instance, while IOM use in thoracic PSOs has been shown to be effective, there is no established consensus on the net impact of IOM use in PSOs of the lumbar spine. While IOM has the potential to mitigate neurological damage, it also increases operation time and cost; thus, it should only be employed in operations where it will have a net positive impact on patient outcomes. The question thus becomes whether PSO of the lumbar spine is one such operation. To address this, we examine the most frequently employed IOM modalities and evaluate their current usage and efficacy in lumbar PSOs. Furthermore, we will also examine the utility of IOM for other surgeries of the lumbar spine, including corrective procedures for idiopathic scoliosis and degenerative scoliosis, and routine lumbar procedures, such as discectomies and decompression surgeries for foraminal and canal stenosis.

BACKGROUND CONTEXT Routine use of magnetic resonance imaging (MRI) as a diagnostic tool in lumbar stenosis is becoming more prevalent due to the aging population. Currently, there is no clinical guideline to clarify the utility of repeat MRI in patients with lumbar stenosis, without instability, neurological deficits, or disc herniation. PURPOSE To evaluate the utility of routine use of MRI as a diagnostic tool in lumbar stenosis, and to help formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis. STUDY DESIGN/SETTING Retrospective radiographic analysis. PATIENT SAMPLE Retrospective chart review was performed to review patients with lumbar stenosis, who underwent lumbar decompression without fusion from 2011 to 2015 at a single institution. OUTCOME MEASURES Previously established stenosis grading systems were used to measure and compare the initial and the subsequent repeat lumbar MRIs performed preoperatively. If patients were found to have a moderate or severe grade change, and if the surgical plan was altered due to such exacerbated radiographic findings, then their grade changes were considered clinically meaningful. METHODS We identified patients with lumbar stenosis without radiographic instability or neurological deficits, who had at least two preoperative lumbar MRIs performed and underwent decompressive surgeries. At each pathologic disc level, the absolute value of the change in grade for central and lateral recess stenosis, right foraminal stenosis, and left foraminal stenosis from the first preoperative MRI to the repeated MRI was calculated. These changed data were then used to calculate the mean and median changes in each of the three types of stenosis for each pathologic disc level. Identical calculations were carried out for the subsample of patients who only underwent discectomy or had a discectomy included as part of their surgery. RESULTS Among the 103 patients who met the inclusion criteria, 37 of those patients had more than one level surgically addressed, and a total of 161 lumbar levels were reviewed. Among the subset of patients that had any grade change, the majority of the grades only had a mild change of 1 (36 out of 42 patients, 85.7%, 95% confidence interval [CI]: 73.1%–94.1%); there was a moderate grade change of 2 in two patients (4.8%, CI: 0.8%–14.0%), and a severe change of 3 in one patient (2.4%, CI: 0.2%–10.1%). There were three patients with decreased grade change (7.1%, CI: 1.8%–17.5%). All clinically meaningful grade changes were from the subset of patients who had only discectomy or discectomy as part of the procedure. Lastly, both patients that had a clinically meaningful grade change had their MRIs performed at an interval of greater than 360 days. CONCLUSIONS The radiographic evaluation of the utility of routinely repeated MRIs in lumbar stenosis without instability, neurological deficits, or disc herniations demonstrated that there were no significant changes found in the repeated MRI in the preoperative setting, especially if the MRIs were performed less than one year apart. The results of this present study can help to standardize the diagnostic evaluation of lumbar stenosis and to formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis patients.

OBJECTIVEComplete radiographic and clinical evaluations are essential in the surgical treatment of cervical spondylotic myelopathy (CSM). Prior studies have correlated cervical sagittal imbalance and kyphosis with disability and worse health-related quality of life. However, little is known about C2–3 disc angle and its correlation with postoperative outcomes. The present study is the first to consider C2–3 disc angle as an additional radiographic predictor of postoperative adverse events.METHODSA retrospective chart review was performed to identify patients with CSM who underwent surgeries from 2010 to 2014. Data collected included demographics, baseline presenting factors, and postoperative outcomes. Cervical sagittal alignment variables were measured using the preoperative and postoperative radiographs. Univariable logistic regression analyses were used to explore the association between dependent and independent variables, and a multivariable logistic regression model was created using stepwise variable selection.RESULTSThe authors identified 171 patients who had complete preoperative and postoperative radiographic and outcomes data. The overall rate of postoperative adverse events was 33% (57/171), and postoperative C2–3 disc angle, C2–7 sagittal vertical axis, and C2–7 Cobb angle were found to be significantly associated with adverse events. Inclusion of postoperative C2–3 disc angle in the analysis led to the best prediction of adverse events. The mean postoperative C2–3 disc angle for patients with any postoperative adverse event was 32.3° ± 17.2°, and the mean for those without any adverse event was 22.4° ± 11.1° (p < 0.0001).CONCLUSIONSIn the present retrospective analysis of postoperative adverse events in patients with CSM, the authors found a significant association between C2–3 disc angle and postoperative adverse events. They propose that C2–3 disc angle be used as an additional parameter of cervical spinal sagittal alignment and predictor for operative outcomes.

OBJECTIVEDeep brain stimulation (DBS) is an effective therapy for movement disorders such as idiopathic Parkinson’s disease (PD) and essential tremor (ET). However, some patients who demonstrate benefit on objective motor function tests do not experience postoperative improvement in depression or anxiety, 2 important components of quality of life (QOL). Thus, to examine other possible explanations for the lack of a post-DBS correlation between improved objective motor function and decreased depression or anxiety, the authors investigated whether patient perceptions of motor symptom severity might contribute to disease-associated depression and anxiety.METHODSThe authors performed a retrospective chart review of PD and ET patients who had undergone DBS at the Cleveland Clinic in the period from 2009 to 2013. Patient demographics, diagnosis (PD, ET), motor symptom severity, and QOL measures (Primary Care Evaluation of Mental Disorders 9-item Patient Health Questionnaire [PHQ-9] for depression, Generalized Anxiety Disorder 7-item Scale [GAD-7], and patient-assessed tremor scores) were collected at 4 time points: preoperatively, postoperatively, 1-year follow-up, and 2-year follow-up. Multivariable prediction models with solutions for fixed effects were constructed to assess the correlation of predictor variables with PHQ-9 and GAD-7 scores. Predictor variables included age, sex, visit time, diagnosis (PD vs ET), patient-assessed tremor, physician-reported tremor, Unified Parkinson’s Disease Rating Scale part III (UPDRS-III) score, and patient-assessed tremor over time.RESULTSSeventy PD patients and 17 ET patients were included in this analysis. Mean postoperative and 1-year follow-up UPDRS-III and physician-reported tremor scores were significantly decreased compared with preoperative scores (p < 0.0001). Two-year follow-up physician-reported tremor was also significantly decreased from preoperative scores (p < 0.0001). Only a diagnosis of PD (p = 0.0047) and the patient-assessed tremor rating (p < 0.0001) were significantly predictive of depression. A greater time since surgery, in general, significantly decreased anxiety scores (p < 0.0001) except when a worsening of patient-assessed tremor was reported over the same time period (p < 0.0013).CONCLUSIONSPatient-assessed tremor severity alone was predictive of depression in PD and ET following DBS. This finding suggests that a patient’s perception of illness plays a greater role in depression than objective physical disability regardless of the time since surgical intervention. In addition, while anxiety may be attenuated by DBS, patient-assessed return of tremor over time can increase anxiety, highlighting the importance of long-term follow-up for behavioral health features in chronic neurological disorders. Together, these data suggest that the patient experience of motor symptoms plays a role in depression and anxiety—a finding that warrants consideration when evaluating, treating, and following movement disorder patients who are candidates for DBS.

OBJECTIVEUsing an imaging-based prospective comparative study of 709 eligible patients that was designed to assess lumbar spinal stenosis (LSS) in the ages between 16 and 82 years, the authors aimed to determine whether they could formulate radiological structural differences between the developmental and degenerative types of LSS.METHODSMRI structural changes were prospectively reviewed from 2 age cohorts of patients: those who presented clinically before the age of 60 years and those who presented at 60 years or older. Categorical degeneration variables at L1–S1 segments were compared. A multivariate comparative analysis of global radiographic degenerative variables and spinal dimensions was conducted in both cohorts. The age at presentation was correlated as a covariable.RESULTSA multivariate analysis demonstrated no significant between-groups differences in spinal canal dimensions and stenosis grades in any segments after age was adjusted for. There were no significant variances between the 2 cohorts in global degenerative variables, except at the L4–5 and L5–S1 segments, but with only small effect sizes. Age-related degeneration was found in the upper lumbar segments (L1–4) more than the lower lumbar segments (L4–S1). These findings challenge the notion that stenosis at L4–5 and L5–S1 is mainly associated with degenerative LSS.CONCLUSIONSIntegration of all the morphometric and qualitative characteristics of the 2 LSS cohorts provides evidence for a developmental background for LSS. Based on these findings the authors propose the concept of LSS as a developmental syndrome with superimposed degenerative changes. Further studies can be conducted to clarify the clinical definition of LSS and appropriate management approaches.

To summarize current evidence on the safety of cataract surgery with and without the femtosecond laser Large studies, including a government-financed randomized controlled trial, have consistently failed to demonstrate any additional safety benefit from femtosecond laser–assisted cataract surgery (FLACS) when compared to manual phaco. Additional high-quality studies, such as the European Society for Cataract and Refractive Surgery EUREQUO FLACS Study, suggest that manual cataract surgery actually has fewer complications. The data on whether FLACS reduces endothelial cell count loss are mixed. Similarly, proof of a significant improvement in refractive outcomes from FLACS has not been demonstrated. Although individual surgeon preferences for FLACS may continue, current evidence shows that it is at best noninferior to standard manual cataract surgery. Given the additional costs associated with use of FLACS, ophthalmologists discussing this technology with patients should take care not to overstate its potential benefits.

OBJECTIVEMultiple sclerosis (MS) is a chronic autoimmune disease that causes demyelination and axonal loss. Walking difficulties are a common and debilitating symptom of MS; they are usually caused by spastic paresis of the lower extremities. Although intrathecal baclofen (ITB) therapy has been reported to be an effective treatment for spasticity in MS, there is limited published evidence regarding its effects on ambulation. The goal of this study was to characterize ITB therapy outcomes in ambulatory patients with MS.METHODSData from 47 ambulatory patients with MS who received ITB therapy were analyzed retrospectively. Outcome measures included Modified Ashworth Scale, Spasm Frequency Scale, Numeric Pain Rating Scale, and the Timed 25-Foot Walk. Repeated-measures ANOVA was used to test for changes in outcome measures between baseline and posttreatment (6 months and 1 year). Significance was set at p < 0.05. Descriptive data are expressed as the mean ± SD, and results of the repeated-measures ANOVA tests and the Wilcoxon rank-sum test are expressed as the mean ± SEM.RESULTSThere was a statistically significant reduction in the following variables: 1) aggregate lower-extremity Modified Ashworth Scale scores (from 14.8 ± 1.0 before ITB therapy to 5.8 ± 0.8 at 6 months posttreatment and 6.4 ± 0.9 at 1 year [p < 0.05]); 2) Numeric Pain Rating Scale scores (4.4 ± 0.5 before ITB, 2.8 ± 0.5 at 6 months, and 2.4 ± 0.4 at 1 year [p < 0.05]); 3) spasm frequency (45.7% of the patients reported a spasm frequency of ≥ 1 event per hour before ITB therapy, whereas 15.6% and 4.3% of the patients reported the same at 6 months and 1 year posttreatment, respectively [p < 0.05]); and 4) the number of oral medications taken for spasticity (p < 0.05). Of the 47 patients, 34 remained ambulatory at 6 months, and 32 at 1 year posttreatment. There was no statistically significant change in performance on the Timed 25-Foot Walk test over time for those patients who remained ambulatory.CONCLUSIONSIn this retrospective study, the authors found that ITB therapy is effective in reducing spasticity and related symptoms in ambulatory patients with MS. Because the use of ITB therapy is increasing in ambulatory patients with MS, randomized, prospective studies are important to help provide a more useful characterization of the effects of ITB therapy on ambulation.

Study Design: In vitro cadaveric biomechanical study. Objectives: Despite numerous techniques employed to establish solid lumbosacral fixation, there are little biomechanical data correlating fixation methods at L5/S1 to thoracolumbosacral (TLS) construct length. We aimed to determine the optimal construct with the hypothesis that under physiological loads, lumbosacral constructs can be stabilized by L5/S1 anterior lumbar interbody fusion (ALIF) alone, without iliac screw fixation (ISF), and that TLS constructs would require ISF, with or without ALIF. Methods: By using a robot capable of motion in 6 axes, force-moment sensor, motion-tracking camera system and software, we simulated the spinal loading effects in flexion-extension, axial rotation, and lateral bending, and compared torques in different construct groups of T4-S1, T10-S1, and L2-S1. By conducting multidirectional flexibility testing we assessed the effects of constructs of various lengths on the L5/S1 segment. Results: L2-S1 constructs may be equivalently stabilized by L5/S1 ALIF alone without ISF. Longer TLS constructs exerted increasing motion at L5/S1, exhibiting trends in favor of ISF when extending to T10 and statistically improved fixation when extending to T4. Lastly, TLS constructs with ISF exhibited a statistically significant reduction in L5-S1 range of motion from the addition of ALIF when extending to T4-pelvis but not T10-pelvis. Conclusions: We found that ALIF alone may sufficiently support the L2-S1 construct, reducing L5/S1 range of motion and transmitting loads instead to the sacropelvis. Furthermore, ALIF was found to add significant stability to the T4-pelvis construct when added to ISF. This difference was not significant for the T10-pelvis construct.

Background We report a series of 3 cases of metastatic thymoma to the spine with spinal cord compression. An extensive literature review of thymic metastases to the spine was completed to provide a comprehensive appraisal of current prognostic indicators and potential treatment algorithms to help guide clinicians in treatment management. Case Descriptions Between 2000 and 2017, 3 patients received diagnoses of thymic metastases to the spine at our institution. Metastasis presentation occurred from 2 to 8 years after the initial diagnosis with thymic cancer. All 3 patients presented with signs and symptoms of spinal cord/cauda equina compression, and underwent surgical intervention. Postoperative treatments varied among all 3 patients, 1 receiving chemotherapy, another undergoing radiation, and the third having had no further treatment because of extensive systemic disease. Conclusions Upon review of the literature, 16 case reports/series described 28 total patients with spine metastases secondary to thymoma/thymic carcinoma. The presentations varied widely, including age, neurologic deficits, time from initial diagnosis to metastasis, and histologic grading. The only widely accepted prognostic factor is completeness of tumor resection, whereas clinical staging, histologic type, or both may also have prognostic value. Thus, gross total resection and spinal decompression should be prioritized in cases of surgical intervention. Chemotherapy and radiotherapy are generally recommended. However, given the lack of standardized treatment algorithms, individualized regimens should be formulated on a case-specific basis.

Background Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity. Objective To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed. Methods The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips. Results A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery. Conclusion The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.

There have been various effective surgical procedures for the treatment of non-syndromic sagittal craniosynostosis, but no definitive guidelines for management have been established. We conducted a study to elucidate the current state of practice and establish a warranted standard of care. An Internet-based study was sent to 180 pediatric neurosurgeons across the country and 102 craniofacial plastic surgeons in fourteen different countries, to collect data for primary indication for surgical management, preference for timing and choice of surgery, and pre-, peri-, and post-operative management options. The overall response rate from both groups was 32% (n=90/284). Skull deformity was the primary indication for surgical treatment in patients without signs of hydrocephalus for both neurosurgeons and craniofacial surgeons (80% and 63%, respectively). Open surgical management was most commonly performed at six months of age by neurosurgeons (46%) and also by craniofacial surgeons (35%). Open surgical approach was favored for patients younger than four months of age by neurosurgeons (50%), but endoscopic approach was favored by craniofacial surgeons (35%). When performing an open surgical intervention, most neurosurgeons preferred pi or reversed pi procedure (27%), whereas total cranial vault remodeling was the most commonly performed procedure by craniofacial surgeons (37%). The data demonstrated a discrepancy in the treatment options for non-syndromic sagittal craniosynostosis. By conducting/comparing a wide survey to collect consolidative data from both groups of pediatric neurosurgeons and craniofacial plastic surgeons, we can attempt to facilitate the establishment of standard of care.

Commercial stem cell therapy and “stem cell tourism” refer to the for-profit industry that has recently experienced a rise in popularity due to the regenerative potential of pluripotent stem cells. Without regulatory oversight, there is a growing concern for the future of legitimate research into stem cell therapy due to exaggerated claims of potential benefit, which in turn can contribute to research misconduct and loss of scientific credibility.1 Associated morbidities such as stem cell-induced lesions are often not given adequate consideration. We present a case illustrating the development of a proliferative lesion after stem cell therapy with a unique morphologic pathology, illustrating this medical conundrum.

OBJECTIVEGamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM.METHODSThe authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome.RESULTSFifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4–21.1 cm3), 14.98 cm3 (range 0.6–71.8 cm3), and 1.23 cm3 (range 0.3–3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0–5.07 cm). The median follow-up time was 7.3 months (range 1.6–57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range −96.95% to +48.69%, p < 0.001), median PTE decreased by 78.10% (range −99.92% to +198.35%, p < 0.001), and the fourth ventricle increased by 24.97% (range −37.96% to +545.6%, p < 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment.CONCLUSIONSIn this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p < 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates.

BACKGROUND: Laser ablation (LA) is used as an upfront treatment in patients with deep seated newly diagnosed Glioblastoma (nGBM). OBJECTIVE: To evaluate the outcomes of LA in patients with nGBM and compare them with a matched biopsy-only cohort. METHODS: Twenty-four nGBM patients underwent upfront LA at Cleveland clinic, Washington University in St. Louis, and Yale University (6/2011-12/2014) followed by chemo/radiotherapy. Also, 24 out of 171 nGBM patients with biopsy followed by chemo/radiotherapy were matched based on age (

Small pupils present a significant challenge for the cataract surgeon, requiring excellent intraoperative decision-making to maximize the likelihood of a successful outcome. Research has indicated that one of the common causes of small pupils, intraoperative floppy iris syndrome (IFIS), increases the likelihood of complications such as posterior capsule rupture and iris trauma. Fortunately, a variety of pharmacologic and mechanical strategies are available to help maintain an adequately dilated pupil to increase the likelihood of successful, safe cataract surgery.

Background The application of laser interstitial thermal therapy (LITT) for intracranial lesions in the posterior fossa tumors remains challenging due to the smaller size of this compartment as well as the thickness and angle of the occipital bone. In this study, we reviewed our experience with this treatment modality for posterior fossa lesions. Methods We retrospectively reviewed our series of 8 patients with posterior fossa tumors treated with LITT from an Institutional Review Board–approved brain tumor database (2012–2017) of more than 200 cases at our institution. Results The 8 patients underwent LITT targeting 3 metastases, 2 pilocytic astrocytomas, 2 zones of radiation necrosis after radiosurgery, and 1 glioblastoma (GBM). The mean preoperative lesion volume was 4.35 cm3. A 6 months postsurgery, the mean lesion volume had decreased from 9.64 cm3 to 5.72 cm3. Two of the tumors (the GBM and a metastatic adenocarcinoma) progressed after 8.5 and 7.5 months, respectively, with mortality after 1.1 and 1.6 years, respectively. Surgical resection was performed in a patient with metastatic adenocarcinoma tumor at 7.7 months after LITT. All other lesions remained stable or were diminished at a median follow-up of 14.8 months (range, 0.4–37.5 months). Magnetic resonance imaging (MRI) on the first postoperative day, showed an increase in mean tumor-related edema volume from 9.45 cm3 to 14.10 cm3. After a postoperative follow-up of at least 1 month, this mean decreased to 8.70 cm3. One case each of transient partial unilateral sixth cranial nerve palsy, superficial wound infection, and a late obstructive hydrocephalus were noted postoperatively. No mortality was associated with the procedure. Conclusions LITT is a safe and feasible treatment modality even in challenging locations like the posterior fossa. However, surgical indications should be tailored for each individual patient based on the size and location of tumor.

To compare the rotational stability of the 2 most commonly used toric intraocular lenses (TIOLs).Retrospective cohort study in a single private practice.The study included all patients receiving an Acrysof (n = 626) or Tecnis TIOL (n = 647) over an 18-month period from April 2015 to September 2016. Patients were only excluded if their surgery could not be performed using a digital marking system.All patients had cataract surgery performed in the same surgical center with a similar technique. A digital marking system with limbal vessel registration was used to record the axis of the TIOL at the conclusion of surgery. A dilated examination was performed either later on the day of surgery or the next morning, and the postoperative rotation of the 2 TIOL models was compared. Patients who required a return to the operating room for TIOL repositioning were examined to determine risk factors for reoperation and subsequent outcomes.The primary outcome measure was the percentage of eyes with TIOL rotation5 and10 degrees. The second main outcome was likelihood of requiring return to the operating room to reposition a rotated TIOL.The Acrysof TIOL was less likely to rotate postoperatively, with 91.9% of eyes rotated ≤5 degrees at the first postoperative check compared with 81.8% of Tecnis TIOL eyes (P0.0001). This difference persisted for rotation ≤10 degrees (97.8% Acrysof vs. 93.2% Tecnis, P = 0.0002) and ≤15 degrees (98.6% Acrysof vs. 96.4% Tecnis, P = 0.02). The mean rotation was 2.72 degrees (95% confidence interval 2.35-3.08 degrees) for Acrysof and 3.79 degrees (95% confidence interval 3.36-4.22 degrees) for Tecnis TIOLs (P0.05). The Tecnis TIOL showed a strong predisposition to rotate counterclockwise, unlike the Acrysof. More Tecnis TIOL patients required repositioning (3.1% vs. 1.6%), but this did not reach statistical significance (P = 0.10). Refractive outcomes were similar between the 2 groups.The Acrysof TIOL showed significantly greater rotational stability than the Tecnis TIOL.

Millions of patients now have online access to their full electronic medical record, including the clinic notes from general and specialty physicians.1–4 At our institution, all clinic notes have been accessible to patients via a secure patient portal since October 2014,5 Subsequently, some patients are now asking their generalist physicians to answer questions about subspecialists’ clinic notes. We conducted the first known survey to assess general physicians’ self-assessed understanding of specialty ophthalmology clinic notes. While general physicians’ understanding of patients’ eye care issues has substantial clinical relevance, we hypothesised that eye clinic notes might be challenging for primary care providers to understand. We administered a print survey to internal medicine interns, residents, fellows and attending physicians at the University of Washington. Participants were recruited at a grand rounds presentation and an outpatient clinic. The survey included three questions about engagement with and understanding of ophthalmology notes and two questions self-rating their understanding of sample ophthalmology clinic notes. Of the 59 responding physicians, the majority reported trying to …

Background: Aneurysmal subarachnoid hemorrhages are frequently complicated by hypertension and neurogenic myocardial stunning. Beta blockers may be used for management of these complications. We sought to investigate sympathetic nervous system modulation by beta blockers and their effect on radiographic vasospasm, delayed cerebral infarction, discharge destination and death. Methods: Retrospective chart review of 218 adults admitted to the ICU between 8/2004 and 9/2010 was performed. Groups were identified relevant to beta blockade: 77 were never beta blocked (No/No), 123 received post-admission beta blockers (No/Yes), and 18 were continued on their home beta blockers (Yes/Yes). Records were analyzed for baseline characteristics and the development of vasospasm, delayed cerebral infarction, discharge destination and death, expressed as adjusted odds ratio. Results: Of the 218 patients 145 patients developed vasospasm, 47 consequently infarcted, and 53 died or required care in a long-term facility. When compared to No/No patients, No/Yes patients had significantly increased vasospasm (OR 2.11 (1.06-4.16)). However, these patients also had significantly fewer deaths or need for long term care (OR 0.17 (0.05-0.64)), with decreased tendency for infarcts (OR 0.70 (0.32-1.55)). When compared to No/No patients, Yes/Yes patients demonstrated a trend toward increased vasospasm (OR 1.61 (0.50-5.29)) that led to infarction (OR 1.51 (0.44-5.13)), but with decreased mortality or need for long term care in a facility (OR 0.13 (0.01-1.30)). Conclusion: Post-admission beta blockade in aneurysmal subarachnoid hemorrhage patients was associated with increased incidence of vasospasm. However, despite the increased occurrence of vasospasm, beta blockers were associated with improved discharge characteristics and fewer deaths.

Surgical resection of the epileptogenic zone (EZ) is a potential cure for medically refractory focal epilepsy. Proper identification of the EZ is essential for such resection. Synergistic application of functional magnetic resonance imaging (fMRI) simultaneously with stimulation of a single externalized intracranial stereotactic EEG (SEEG) electrode has the potential to improve identification of the EZ. While most EEG-fMRI studies use the electrodes passively to record electrical activity, it is possible to stimulate the brain using the electrodes by connecting them with conducting cables to the stimulation hardware. In this study, we investigated the effect of MRI-induced heating on a single SEEG electrode and its sensitivity to geometry, configuration, and associated connections required for the stimulation. The temperature increase of a single electrode embedded within a gel phantom and connected to an external stimulation system was measured during 1.5T MRI scans using adjacent fluoroptic temperature sensors. A receive-only split-array head coil and a transmit-receive head coil were used for testing. Sequences included a standard localizer, T1-weighted axial fast low-angle shot (FLASH), gradient echo-planar imaging (GE-EPI) axial fMRI, and a high specific absorption rate T2-weighted turbo spin-echo (TSE) axial scan. Variations of the electrode location and connecting cable configuration were tested. No unacceptable heating was observed with the standard sequences used for evaluation of the EZ. Considerable heating (up to 14°C) was observed with the TSE sequence, which is not used clinically. The temperature increase was insignificant (0.05°C) for electrode contacts closest to the isocenter and connecting cables lying along the isocenter, and varied with configurations of the connecting cable assembly. Simultaneous intracranial electrode stimulation during fMRI using an externalized stimulation system may be safe with strict adherence to settings tested prior to the fMRI. Localizer, FLASH, and GE-EPI fMRI may be safely performed in patients with a single SEEG electrode following the configurations tested in this study, but high SAR TSE scans should not be performed in these patients.

Purpose This study aimed to understand patients' perceptions about potential benefits and harms of accessing their own ophthalmology clinic notes via an electronic patient portal as part of the OpenNotes initiative. Methods The authors conducted a cross-sectional, in-person survey of ophthalmology patients at three US eye clinics. The paper survey was self-administered or administered with assistance from study staff before or after patients' clinical visits. The authors used descriptive statistics to summarise patient characteristics and patient attitudes about accessing their ophthalmology notes online. Chi-square and t-tests were performed to assess differences in patient responses between clinic locations. Results Four hundred and fifty-one patients responded (response rate 65%). Most patients thought that accessing doctors' notes online was a good idea (95%), wanted to view their clinic notes online (94%), and agreed online access would increase their understanding of their eye problems (95%) and help them better remember their care plan (94%); 14% said online access would increase their worry; 43% had privacy concerns; and 96% indicated they would show or discuss their notes with at least one other person. Non-white patients were more likely than white patients to perceive online clinic notes as a useful tool, but they were also more likely to worry and to express greater privacy concerns. Conclusions Patients at three US eye clinics were strongly in favour of online access to ophthalmology notes and were optimistic this access would improve their understanding and self-care. Ophthalmologists should consider offering online access to their notes to enhance doctor-patient communication and improve clinical outcomes.

OBJECTIVE Ossification of the posterior longitudinal ligament (OPLL) is a pathological calcification or ossification of the PLL, predominantly occurring in the cervical spine. Although surgery is often necessary for patients with symptomatic neurological deterioration, there remains controversy with regard to the optimal surgical treatment. In this systematic review and meta-analysis, the authors identified differences in complications and outcomes after anterior or posterior decompression and fusion versus after decompression alone for the treatment of cervical myelopathy due to OPLL. METHODS A MEDLINE, SCOPUS, and Web of Science search was performed for studies reporting complications and outcomes after decompression and fusion or after decompression alone for patients with OPLL. A meta-analysis was performed to calculate effect summary mean values, 95% CIs, Q statistics, and I2 values. Forest plots were constructed for each analysis group. RESULTS Of the 2630 retrieved articles, 32 met the inclusion criteria. There was no statistically significant difference in the incidence of excellent and good outcomes and of fair and poor outcomes between the decompression and fusion and the decompression-only cohorts. However, the decompression and fusion cohort had a statistically significantly higher recovery rate (63.2% vs 53.9%; p < 0.0001), a higher final Japanese Orthopaedic Association score (14.0 vs 13.5; p < 0.0001), and a lower incidence of OPLL progression (< 1% vs 6.3%; p < 0.0001) compared with the decompression-only cohort. There was no statistically significant difference in the incidence of complications between the 2 cohorts. CONCLUSIONS This study represents the only comprehensive review of outcomes and complications after decompression and fusion or after decompression alone for OPLL across a heterogeneous group of surgeons and patients. Based on these results, decompression and fusion is a superior surgical technique compared with posterior decompression alone in patients with OPLL. These results indicate that surgical decompression and fusion lead to a faster recovery, improved postoperative neurological functioning, and a lower incidence of OPLL progression compared with posterior decompression only. Furthermore, decompression and fusion did not lead to a greater incidence of complications compared with posterior decompression only.

Patients are accessing their medical records via online portals, uploading data into their records, and reading their clinicians' notes. Although these changes hold promise for improving the value ...

Background Electronic health records (EHRs) have become a mandated part of delivering health care in the United States. The purpose of this study is to report patient volume before and after the transition to EHR in an academic outpatient ophthalmology practice. Methods Review of patient visits per half-day and number of support staff for established faculty ophthalmologists between July and October for five consecutive years beginning the year before EHR implementation. Results Eight physicians met inclusion criteria for the study. The number of patient visits was lower in each year after EHR adoption compared to baseline p ≤ 0.027). Patient volume per provider was reduced an average of 16.9 % over the 4 years (range 15.3–18.5 %), and during the final year studied, no provider had returned to the pre-EHR number of patients per clinic session. Support staffing was unchanged (p > 0.2). Conclusions Adoption of EHR was associated with a significantly reduced number of patient visits per clinic session in an academic setting in which support staffing remained stable. Maintaining clinic volume and access in similar settings may require use of additional staffing.