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Avi Toiv, Asad F Durrani, Yunshu Zhou, Peter Y Zhao, David C Musch, Michael J Huvard, David N Zacks Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USACorrespondence: David N Zacks, Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI, 48105, USA, Tel +1 734-232-8404, Fax +1 734-232-8030, Email Davzacks@med.umich.eduPurpose: At the time of open globe injury (OGI), it may be difficult for clinicians to predict which eyes are at highest risk for requiring enucleation. We performed a 17-year retrospective cohort study to report outcomes and risk factors for enucleation following open globe injuryto better aid clinicians counseling patients at OGI diagnosis.Methods: A retrospective cohort study of all patients who presented to the University of Michigan with open globe injury (OGI) and were surgically managed between January 2000 and July 2017 was conducted. At least 30 days of follow-up was required. All eyes that ultimately underwent enucleation following OGI were identified and their clinical course analyzed. The main outcome measured was the rate of enucleation after OGI.Results: There were 587 eyes meeting inclusion criteria. The mean patient age was 40.75 ± 25.1 (range 1– 91). 441/585 (75.4%) patients were male. Average follow-up time was 1029.9 ± 1285.9 days. 116/587 eyes (19.8%) required enucleation after OGI, with 81.9% undergoing enucleation less than 30 days from injury. In enucleated eyes, the mean presenting logMAR vision was 2.91 ± 0.47 (Snellen equivalent between hand motion and light perception). The most common mechanism of injury requiring enucleation was globe rupture, 89/116 (76.7%), with 14/116 (12.1%) penetrating injuries and 13/116 (11.2%) perforating injuries. The mean age of patients that underwent enucleation was 45.6 ± 22.5 (range 3– 91).Conclusion: Open globe injuries are often visually devastating and a significant number of cases ultimately require enucleation. Despite emergent closure within 24 hours, 19.8% of eyes managed for OGI at our institution required eventual enucleation. 81.2% of these eyes required enucleation within 30 days of injury. Wound length greater than 10 mm, uveal prolapse, higher zone of injury, IOFB, and RAPD were identified as risk factors that predict future need for enucleation.Keywords: ocular trauma, open globe repair, globe rupture, eye injury, enucleation

To describe the prevalence, clinical and imaging characteristics, and surgical utility of large internal limiting membrane (ILM) tears in eyes with epiretinal membrane (ERM).Retrospective interventional case series.This was a single-institution study including 71 eyes of 70 consecutive patients that underwent ERM peeling by a single vitreoretinal surgeon between 2016 and 2019. Demographic and clinical data were collected from the medical record. ERMs and large ILM tears were identified and analyzed on multimodal imaging. The main outcome measures were the prevalence and characteristics of large ILM tears in eyes undergoing ERM peeling.Large ILM tears were present in 23 of 71 eyes (32.4%) with ERM that underwent surgical management. A review of patients with ERM during the same period who did not undergo surgical management found large ILM tears in 8 of 100 eyes (8.0%). Large ILM tears were commonly associated with other signs of ERM-induced retinal traction, including retinal nerve fiber layer schisis in 20 of 23 eyes (87.0%), inner retinal dimpling in 8 of 23 eyes (34.8%), and discrete paravascular red lesions in 16 of 19 eyes (84.2%). In all eyes stained with brilliant blue G, the preoperative diagnosis of large ILM tear was confirmed and the scrolled ILM edge was used successfully to initiate ILM peeling.Large ILM tears are often present in eyes undergoing surgery for ERM and are likely caused by ERM contracture. Careful preoperative identification of these tears is helpful for surgical planning because the scrolled flap of ILM provides a convenient and safe "handle" for initiating membrane peeling.

Purpose To characterize the risk factors, clinical presentations, management, outcomes, and microbiological properties of Streptococcus pyogenes keratitis. Methods Eight culture-proven cases (eight eyes) of S. pyogenes keratitis were diagnosed and treated between 2008 and 2018 at the University of Pittsburgh Medical Center (UPMC). Medical records were available for six patients, and these were reviewed to identify demographic information, systemic and ocular history, clinical presentations, antibiotic sensitivity, treatments, and outcomes of S. pyogenes isolates. Results Of the six charts reviewed, the median patient age was 67 years and all patients were female. Four patients had a history of cataract extraction more than one year prior to presentation, one had a history of improper contact lens use, and one had basement membrane dystrophy. Two patients, who also happened to have the most serious medical comorbidities, presented with corneal perforation on initial examination. The median follow-up length was 90.5 days. Visual outcomes varied greatly between patients. Three patients had visual acuity ranging from 20/30 to 20/70, while the two patients with corneal perforation had a final visual acuity of light perception, and one patient was lost to follow-up. Five of six isolates were susceptible to fluoroquinolones and all isolates were susceptible to cefazolin. Conclusions S. pyogenes represented an uncommon ocular pathogen at UPMC eye clinic. However, if left untreated, this infection resulted in severe ocular morbidity. The majority of patients had a benign ocular history, suggesting that S. pyogenes can infect healthy corneas in immunocompetent patients. The majority of isolates were susceptible to cefazolin and fluoroquinolones.

Endothelial keratoplasty has evolved tremendously since its inception. Thick Descemet stripping automated endothelial keratoplasty (DSAEK) grafts have made sway for slimmer ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). This review discusses the recent literature comparing outcomes of UT-DSAEK, DSAEK, and Descemet membrane endothelial keratoplasty (DMEK).DMEK provides quick visual recovery and has remarkably low incidence of graft rejection. However, the learning curve is long compared to DSAEK. UT-DSAEK utilizes donor grafts less than 100-μm thick. Recent studies comparing DMEK and UT-DSAEK have shown DMEK has better visual outcomes with similar rejection rates.UT-DSAEK remains an excellent surgical option for endothelial keratoplasty in eyes with complex anterior segment anatomy. The visual outcomes after UT-DSAEK have been shown to be superior when compared with DSAEK. Recent studies show that DMEK provides better visual outcomes compared with UT-DSAEK.

Scleral buckling is a method of reattaching the neurosensory retina to the retinal pigment epithelium when retinal detachment occurs. While the buckle procedure has high success rates in terms of reattaching the retina, the forces created by encircling and segmental buckles can alter the biomechanical properties of the eye and many of its structures, including axial length, corneal power, astigmatism, corneal hysteresis, corneal resistance factor, anterior chamber depth, ocular volume, ocular rigidity, and ocular blood flow. This chapter delves into the biomechanical changes induced by scleral buckling.

To characterize the risk factors, clinical presentations, management choices, and outcomes of Proteus mirabilis keratitis.In this retrospective study, 26 culture-proven cases of P. mirabilis infections were diagnosed and treated between 1998 and 2019 at the University of Pittsburgh Medical Center. Medical records were available for 14 keratitis cases and were reviewed for demographic information, ocular risk factors, and treatment outcomes.Sixteen eyes of 14 patients were included in the study. The average age was 47.8 ± 19.3 years, with a median follow-up time of 6 months. The most common ocular risk factors were poor ocular surface and contact lens use in 57.1% and 42.9% of cases, respectively. Eleven of the 14 patients (78.6%) had positive corneal cultures, and 13 of the 14 patients (92.9%) had positive conjunctiva or eyelid cultures. All isolates were susceptible to ciprofloxacin, ofloxacin, moxifloxacin, gatifloxacin, and cefazolin. Surgical intervention was required in 4 patients (28.6%). Average LogMAR visual acuity was 1.3 ± 1.0 at presentation and 0.9 6 ± 1.0 at the most recent follow-up visit.Proteus mirabilis is an uncommon cause of microbial keratitis. Patients with poor ocular surface and those who use contact lens are at increased risk for developing this cause of keratitis. Empiric treatment with fortified antibiotics or fluoroquinolones seemed to provide effective coverage for P. mirabilis.

Purpose To analyze the risk factors, clinical characteristics, management, and treatment outcomes of culture-proven cases of Moraxella keratitis at our center. Design Retrospective observational case series. Methods Thirty-nine culture-proven cases of Moraxella keratitis (39 eyes) diagnosed and treated between January 2003 and April 2018 at the University of Pittsburgh Medical Center were identified and retrospectively reviewed for ocular and systemic risk factors, treatment modalities, and outcomes, as well as for antimicrobial sensitivity and resistance data. Results The mean age of the 39 patients was 63.0 (range 4-95 years) with median follow-up time of 170 days. Thirty-four of 39 patients (87.2%) had an ocular risk factor, the most common of which were blepharitis in 12 (30.8%), dry eyes in 12 (30.8%), and history of ocular surgery in 9 (23.1%). History of diabetes mellitus was found in 8 patients (20.5%). Thirty-six of 39 patients (92.3%) received a fluoroquinolone (92.3%) and 30 of 39 (76.7%) received topical fortified antibiotics. Resistance to fluoroquinolones, gentamicin, and tobramycin was seen in 1 patient each, respectively. Four patients (10.3%) required tarsorrhaphy, 6 patients (15.4%) required penetrating keratoplasty, and 1 patient required enucleation. Of the 35 patients for whom visual acuity information was available, 19 (54.3%) were count fingers or worse at most recent follow-up. Conclusions Ocular risk factors, especially poor ocular surface, were identified in the vast majority of patients with Moraxella keratitis. Moraxella isolates in our study were susceptible to fluoroquinolones and aminoglycosides. Many patients required surgical intervention and the final visual acuity was often poor.

BACKGROUND: Although elevated body mass index (BMI) is a risk factor for cardiac disease, patients with elevated BMI have better survival in the context of severe illness, a phenomenon termed the “obesity paradox.” HYPOTHESIS: Higher BMI is associated with lower mortality in sudden cardiac arrest (SCA) survivors. METHODS: Data were collected on 1433 post‐SCA patients, discharged alive from the hospitals of the University of Pittsburgh Medical Center between 2002 and 2012. Of those, 1298 patients with documented BMI during the index hospitalization and follow‐up data constituted the study cohort. RESULTS: In the overall cohort, 30 patients were underweight (BMI

Purpose To report a case of Nocardia farcinica keratitis in a pediatric contact lens wearer. Methods Case report and literature review. Results A pediatric contact lens wearer was initially misdiagnosed with a poorly healing corneal abrasion after swimming with his contact lenses. On examination at our center, he was found to have a 2.5 by 2.5 mm corneal infiltrate with feathery margins. Microbiology revealed N. farcinica keratitis, which was treated with topical amikacin. The patient returned to his baseline visual acuity after treatment. Conclusions Nocardia keratitis can be misdiagnosed because of its low prevalence, especially in young patients. Prompt diagnosis is important for proper management in these cases. The infection resolved in our patient with prompt diagnosis and treatment with topical amikacin eye drops.

Purpose To analyze the clinical characteristics, management choices, and outcomes of cases of methicillin-resistant Staphylococcus aureus (MRSA) keratitis. Design Retrospective interventional case series. Methods Fifty-two culture-proven (52 eyes) cases of MRSA keratitis diagnosed and treated at the University of Pittsburgh Medical Center were identified and reviewed. Results The mean age was 66.6 ± 19.2 years with a median follow-up time of 147 days. The most prevalent risk factors included a history of ocular surgery (62.5%), topical corticosteroid use (35.4%), and dry eye syndrome (37.5%). There was a high burden of systemic disease (95.8%). The average presenting logarithm of minimal angle of resolution visual acuity was 1.7 ± 0.8 and the average final logarithm of minimal angle of resolution visual acuity was 1.2 + 1.0. Initial antibiotic treatment varied, with 20.8% receiving moxifloxacin alone, 20.8% receiving fortified cefazolin and fortified tobramycin together, and 12.5% receiving fortified vancomycin and fortified tobramycin, although other antibiotics were used during treatment if warranted. Surgical management was often required as 17.3% of eyes perforated: 13.5% required tarsorrhaphy, 5.8% required penetrating keratoplasty, and 1 eye was enucleated. When patients treated with fourth-generation fluoroquinolones were compared with those treated with fortified vancomycin, no difference in final visual acuity, treatment duration, or need for surgery was found. Conclusion MRSA causes fulminant keratitis often requiring surgical management with poor visual acuity outcomes. Poor ocular surface, topical corticosteroid use, previous ocular surgery, and/or a high burden of systemic disease were identified as common risk factors. Patients treated with fluoroquinolones in our study had comparable outcomes to those treated with fortified vancomycin; however, those treated with fortified vancomycin tended to have more severe ulcers at presentation.

Cytomegalovirus (CMV) keratitis, albeit an uncommon manifestation of this ubiquitous pathogen, can lead to devastating ocular morbidity. Timely diagnosis and appropriate treatment are also unfortunately uncommon. The purpose of this review is to discuss recently published literature regarding the epidemiology, pathophysiology, diagnosis, and therapy of CMV keratitis.Classic clinical presentations of CMV keratitis are known; however, current investigations further elucidate characteristics of typical versus atypical disease. Ongoing research stems beyond utilizing PCR analysis towards targeted diagnostic studies with advanced imaging modalities as well as modern genotyping techniques. Strong clinical acumen combined with appropriate handling of these modern technologies are proving invaluable for rapid diagnosis and treatment of this virulent pathogen.The current recommended treatment for CMV keratitis is systemic ganciclovir. Astute clinicians must consider this diagnosis in any patient with keratitis, anterior uveitis, and intraocular hypertension. Novel diagnostic techniques should be combined with clinical exam findings to accurately and efficiently diagnose, treat, and monitor progression.

Background: Current guidelines recommend implantable cardioverter-defibrillator (ICD) therapy in survivors of sudden cardiac arrest (SCA), except in those with completely reversible causes. We sought to examine the impact of ICD therapy on mortality in survivors of SCA associated with reversible causes. Methods and Results: We evaluated the records of 1433 patients managed at our institution between 2000 and 2012 who were discharged alive after SCA. A reversible and correctable cause was identified in 792 (55%) patients. Reversible SCA cause was defined as significant electrolyte or metabolic abnormality, evidence of acute myocardial infarction or ischemia, recent initiation of antiarrhythmic drug or illicit drug use, or other reversible circumstances. Of the 792 SCA survivors because of a reversible and correctable cause (age 61±15 years, 40% women), 207 (26%) patients received an ICD after their index SCA. During a mean follow-up of 3.8±3.1 years, 319 (40%) patients died. ICD implantation was highly associated with lower all-cause mortality ( P P P Conclusions: In survivors of SCA because of a reversible and correctable cause, ICD therapy is associated with lower all-cause mortality except if the SCA was because of myocardial infarction. These data deserve further investigation in a prospective multicenter randomized controlled trial, as they may have important and immediate clinical implications.

Objectives To assess the optimal length of follow-up for patients undergoing both open and minimally invasive pyeloplasties to ensure prompt detection of a recurrent obstruction. There are no standard guidelines on ideal follow-up and imaging post-pediatric pyeloplasty currently. Methods A retrospective chart review identified 264 patients (

Racial disparities between African American (AA) and White patients have been documented in cardiovascular disease. We investigated whether these disparities exist in patients undergoing rhythm control for atrial fibrillation (AF). 5873 AF patients (241 AA) were followed to the endpoint of death, stroke, or AF recurrence. Invasive procedures for AF rhythm control were examined in both racial groups. Over a mean follow-up time of 40 months, AA patients had a higher adjusted risk of death [HR 1.39, 95% CI 1.00–1.92, p = 0.043] and stroke [HR 1.90, 95% CI 1.13–3.15, p = 0.013] but a lower risk of AF recurrence [HR 0.79, 95% CI 0.63–0.97, p = 0.026]. In addition, AA patients were less likely to undergo AF ablation (p = 0.006) or surgical maze (p = 0.032) procedures compared to White patients, possibly due to the lower rates of AF recurrence. Significant racial disparities exist in the management and outcomes of AA and White patients undergoing rhythm control management for AF.

Background Quadripolar left ventricular (LV) leads are capable of pacing from four different electrodes which allows for easier and more stable intra-operative lead positioning with optimal pacing parameters. We therefore investigated the rate of combined intra-operative and post-operative LV lead related events in quadripolar vs. bipolar LV lead cardiac resynchronization therapy (CRT) recipients in the real world setting. Methods We retrospectively collected data for N = 1441 patients at our institution implanted with quadripolar (n = 292) or bipolar (n = 1149) LV leads from 2012 to 2014 and followed them to the primary end-point of composite lead outcome defined as intra-operative lead implant failure or post-operative lead dislodgement or deactivations. Results Patients implanted with a quadripolar lead were younger (70.6 ± 11.4 vs 72.5 ± 11.6, p = 0.014) and had higher incidence of diabetes (41.8% vs 32.8%, p = 0.004) compared to those with bipolar leads. All other baseline characteristics were comparable. Patients implanted with a quadripolar were significantly less likely to reach the primary endpoint in the first 12 months after LV lead implantation (Hazard Ratio 0.22, 95% Confidence Interval 0.08–0.60, p = 0.001). There were no differences between the two groups in rates of hospitalization for any cause or in mortality. Conclusion In this real world study, quadripolar LV leads have significantly lower rates of implantation failure and post-operative lead dislodgement or deactivation. These results have important clinical implications to CRT recipients.

Introduction: Racial disparities in cardiovascular therapies and outcomes have been previously reported. We sought to investigate the risks of stroke and death in African American (AA) and white patients undergoing rhythm control of atrial fibrillation (AF). Hypothesis: AA patients have greater risk of stroke and death compared to white patients. Methods: We collected data on 5632 white and 241 AA patients that initiated rhythm control therapy for AF at our institution from 2006-2013. Cox proportional-hazards models were used to assess risk factors for stroke and mortality by race. Results: Patients were followed for a median of 40 months (range 1-101). AA patients had higher risk of stroke (6.6% vs. 3.9%, p=0.01) and all-cause mortality (16.2% vs. 13.1%, p=0.03) than white patients. Multivariate modeling confirmed the higher risk of stroke (HR=1.98, 95% CI [1.18-3.31], p=0.01) and mortality (HR=1.49, 95% CI [1.04-2.06], p=0.02) in AA patients after adjusting for baseline differences between race groups (age, HTN, DM, heart failure, and chronic kidney disease). AA patients with DM had an especially high risk of stroke (see Figure). Conclusions: African-American patients treated with a rhythm management strategy had significantly greater risk of stroke and all-cause mortality compared to white patients. AA patients with DM had an especially high risk, but the difference between AA patients vs. white patients was not explained by differences in baseline risk factors. Further investigation is required to determine the root causes of these racial disparities.