Area Of Fundus Research Articles

Endoscopic treatment of patients with idiopathic hydrocephalus with extraventricular cisternal obstruction of the cerebrospinal tract

The possibility of developing extraventricular CSF pathways obstruction was demonstrated in the mid-20th century. The development of neuroimaging (mainly MRI) and endoscopic techniques made it possible to plan and perform minimally invasive surgeries in a narrow anatomical corridor and achieve the regression of neurological symptoms. Purpose of the study: to determine the effectiveness of endoscopic surgery for hydrocephalus due to idiopathic extraventricular CSF pathways obstruction. Materials and methods. Sixty-five patients with signs of extraventricular obstruction underwent examination and surgical treatment at the Center of Neurosurgery from 2007 to 2020. The preoperative Kiefer Scale score was 6.8±3.3 (0-15) points, and the Rankin Scale score — 2.2±1 (0-5) points. Endoscopic third ventriculocisternostomy was performed as the first operation in 42 (64.6 %) patients. Ventriculoperitoneal shunting was performed in 17 (26.1 %) patients. Six (9.2 %) patients were not operated on. Results. After endoscopic surgery, the condition of the patients significantly improved (p < 0.001) after 2 and 12 months. Complete or partial regression of symptoms was noted in 85 % of the patients 1 year after surgery. After shunt surgery, the trend was comparable. The only radiological parameter that changes and correlates with the patients’ condition is the position of the premammillary membrane and the flow void. The remaining indicators of the CSF system of the brain did not actually change. In all cases of the endoscopic surgery, an additional membrane conglomerate that corresponded to preoperative tomograms was found under the premammillary membrane. Conclusion. The high efficiency of endoscopic third ventriculocisternostomy allows recommending this technique as the primary one in patients with extraventricular CSF pathways obstruction, with the exception of cases of anatomy abnormalities of the third ventricular fundus area (short premammillary membrane in combination with a high-lying basilar bifurcation) and cisterns of the posterior cranial fossa base (narrow cisterns, whose dimensions do not allow inserting an endoscope under the premamillary membrane).

Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry.

Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

Central and peripheral changes in the retina and choroid in patients with diabetes mellitus without clinical diabetic retinopathy assessed by ultra-wide-field optical coherence tomography angiography.

To explore the central and peripheral retinal and choroidal changes in diabetic patients without clinical diabetic retinopathy (DM-NoDR) using ultra-wide-field swept-source optical coherence tomography angiography (UWF-SS-OCTA). 67 DM-NoDR eyes and 32 age-matched healthy eyes were recruited. Retinal and choroidal parameters, including qualitative retinal microangiopathy, vessel flow (VFD) and linear density (VLD), thickness, and volume, were measured in the central and peripheral areas of the 24 × 20 mm2 UWF-SS-OCTA images. DM-NoDR eyes had significantly more nonperfusion area and capillary tortuosity than controls in the central and peripheral areas (p < 0.05). The presence of central capillary tortuosity was associated with higher levels of serum creatinine (OR 1.049, 95%CI 1.001-1.098; p = 0.044) and blood urea nitrogen (OR 1.775, 95%CI 1.051-2.998; p = 0.032) in DM-NoDR eyes. For DM-NoDR eyes versus controls, VFD in the 300-μm annulus around the foveal avascular zone, superficial capillary plexus (SCP), and full retina, and SCP-VLD significantly decreased, while VFD in the deep capillary plexus (DCP), retinal thickness, and retinal volume increased (p < 0.05). Analysis in the central and peripheral areas recapitulated all these findings, except for decreased peripheral thickness and volume and no difference in peripheral DCP-VFD. In DM-NoDR eyes, choriocapillaris-VFD, choroidal thickness, and choroidal volume increased in the central area, while VFD in the large and medium choroidal vessel layer decreased in the whole image (p < 0.05). Retinal and choroidal changes already existed in the central and/or peripheral areas of DM-NoDR eyes. UWF-SS-OCTA, enabling the visualization of the peripheral fundus area, is a promising image technique for the early detection of fundus changes in DM-NoDR patients.

Real-time fundus reconstruction and intraocular mapping using an ophthalmic endoscope.

Robotic ophthalmic endoscope holders allow surgeons to execute dual-hand operations in eye surgery. To prevent needle-like endoscopes from invading the retina when moving, surgeons expect visual and real-time information about the relative special relationship between the endoscope and fundus. This study develops a real-time fundus reconstruction method. First, using deep learning, the method estimates the distance between the fundus part corresponding to every pixel of the RGB endoscopic image and the endoscope. Then, by combining the estimated distance with the kinematics of a robotic holder, the point cloud representing the present fundus area is generated, and by which the size and position of the eyeball are estimated. This method shows a real-time frequency of 10Hz, which is robust to eyeball movement. The error of fundus reconstruction is about 0.5mm, and the error of eyeball estimation is about 1mm. Using this fundus reconstruction method can map the position of the endoscope inside the eyeball when using a robotic endoscope holder in eye surgery. The overall accuracy level meets the ophthalmologists' accuracy requirements of ophthalmologists.

Application of Artificial Intelligence to Quantitative Assessment of Fundus Tessellated Density in Young Adults with Different Refractions

Introduction: The aim of this study was to quantitatively assess fundus tessellated density (FTD) and associated factors by artificial intelligence (AI) in young adults. Methods: A total of 1,084 undergraduates (age, 17–23 years old) were enrolled in November 2021. The students were divided into three groups according to axial length (AL): group 1 (AL <24.0 mm, n = 155), group 2 (24 mm ≤ AL <26 mm, n = 578), and group 3 (AL ≥26 mm, n = 269). FTD was calculated by extracting the fundus tessellations as the regions of interest (circle 1, diameter of 3.0 mm; circle 2, diameter of 6.0 mm) and then calculating the average exposed choroid area per unit area of fundus. Results: Among 1,084 students, 1,002 (92.5%) students' FTDs were extracted. The mean FTD was 0.06 ± 0.06 (range, 0–0.40). In multivariate analysis, FTD was significantly associated with male sex, longer AL, thinner subfoveal choroid thickness (SFCT), increased choriocapillaris vessel density (VD), and decreased deeper choroidal VD (all p < 0.05). In circle 1 (diameter of 3.0 mm) and circle 2 (diameter of 6.0 mm), analysis of variance showed that the FTD of the nasal region (p < 0.05) was significantly larger than that of the superior, inferior, and temporal regions. Conclusion: AI-based imaging processing could improve the accuracy of fundus tessellation diagnosis. FTD was significantly associated with a longer AL, thinner SFCT, increased choriocapillaris VD, and decreased deeper choroidal VD.

Obstetric complications in women who underwent conservative myomectomy before pregnancy

The article presents a literature review devoted to the obstetric complications in pregnant women after conservative myomectomy. The attention is paid to such a complication as uterine rupture. The authors consider impractical to evaluate the uterine scar before pregnancy using ultrasound methods and hysteroscopy.Uterine rupture of any type should be documented in the medical history (published), which allows the clinicians and women to better understand factors associated with the risk for rupture and to inform the patient’s decision to deliver by cesarean section or through the vagina.A review and analysis of a case of uterine rupture in a patient after conservative myomectomy is also performed. A 40-weeks pregnant woman was taken to the operating room 12 hours after the start of the acute uterine rupture clinic and decrease of hemodynamic parameters. About 2 liters of blood was found in the abdominal cavity, and a tear up to 7 cm long was determined in the area of the uterine fundus, closer to the left uterine angle. In the female outpatient consultation, during the observation of a pregnant woman who had the laparoscopic intervention – myomectomy, a diagnosis of “scar on the uterus” was not established. Medical documentation providing information on prior surgery was ignored and was not required. During the observation of the pregnant woman, the method of childbirth was not considered by the doctor’s council, and prenatal hospitalization was not performed.By studying the modern scientific sources, there is very little data about factors what increase the risk of uterine rupture, such as penetration into the uterine cavity. Performance of laparoscopic intervention, as a rule, is associated with the implementation of reproductive function in the future. Obstetricians and gynecologists who perform surgical intervention should describe the operation protocol not formally, but taking into account the implementation of the reproductive function. For many women after myomectomy, vaginal delivery can be a safe and feasible option, with patient choice and informed consent regarding the mode of delivery is important. Women should be offered choice and provided with appropriate counseling using all available evidence and monitored during pregnancy and birth in health care institutions that support their choice. This article provides practical recommendations for the management of pregnancy and childbirth in patients who had conservative myomectomy.

Choroidal vascularity profile in diabetic eyes using wide field optical coherence tomography.

To report the wide-field choroidal vascularity up to the mid-equator area in diabetic retinopathy (DR) subjects using wide-field optical coherence tomography (WF-OCT). Prospective, Cross-sectional study. Forty-seven eyes of 25 DR subjects. WF-OCT images (55 degrees) were obtained using Spectralis HRA + OCT (Heidelberg Engineering, Germany) in extremes of gazes in all quadrants and manual montages were created to obtain wide field images up to mid equator. A previously reported semi-automated algorithm was used to calculate choroidal vascularity profile (CVI). Regression analysis was performed to identify the factors influencing CVI. Forty-seven eyes from 25 patients were enrolled in the study. The mean age was 68.4 ± 10.6 years. The refractive error (spherical equivalent) ranged from -2.25 to +3.75 diopters. Most common DR grade among study subjects was moderate NPDR (29.41%) and 74.5% eyes had diabetic macular edema (DME). The mean CVI in the macular area (58.29 ± 3.63) was significantly lower than in any of the other fundus areas (all p ˂ 0.01). The maximum CVI was seen in the nasal region (66.60 ± 5.61), followed by temporal (65.69 ± 3.81), superior (65.01 ± 4.87), and inferior (63.80 ± 5.42). The vertical macular area had the least coefficient of variation (CV) of CVI (0.06) while the inferior quadrant had the highest CV (0.08). The current study describes the CVI profile on WF-OCT in DR eyes up to mid-equator. The significant increase of the CVI compared to healthy subjects and its significant regional variations introduce this novel quantitative parameter as a reliable biomarker of the diabetes-induced choroidal microangiopathy.

Combining fluorescence lifetime with spectral information in fluorescence lifetime imaging ophthalmoscopy (FLIO).

Fluorescence lifetime imaging ophthalmoscopy (FLIO) provides information on fluorescence lifetimes in two spectral channels as well as the peak emission wavelength (PEW) of the fluorescence. Here, we combine these measures in an integral three-dimensional lifetime-PEW metric vector and determine a normal range for this vector from measurements in young healthy subjects. While for these control subjects 97 (±8) % (median (interquartile range)) of all para-macular pixels were covered by this normal vector range, it was 67 (±55) % for the elderly healthy, 38 (±43) % for age-related macular degeneration (AMD)-suspect subjects, and only 6 (±4) % for AMD patients. The vectors were significantly different for retinal pigment epithelium (RPE) lesions in AMD patients from that of non-affected tissue (p < 0.001). Lifetime- PEW plots allowed to identify possibly pathologic fundus areas by fluorescence parameters outside a 95% quantile per subject. In a patient follow-up, changes in fluorescence parameters could be traced in the lifetime-PEW metric, showing their change over disease progression.

Spectrally resolved autofluorescence imaging in posterior uveitis

Clinical discrimination of posterior uveitis entities remains a challenge. This exploratory, cross-sectional study investigated the green (GEFC) and red emission fluorescent components (REFC) of retinal and choroidal lesions in posterior uveitis to facilitate discrimination of the different entities. Eyes were imaged by color fundus photography, spectrally resolved fundus autofluorescence (Color-FAF) and optical coherence tomography. Retinal/choroidal lesions’ intensities of GEFC (500–560 nm) and REFC (560–700 nm) were determined, and intensity-normalized Color-FAF images were compared for birdshot chorioretinopathy, ocular sarcoidosis, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), and punctate inner choroidopathy (PIC). Multivariable regression analyses were performed to reveal possible confounders. 76 eyes of 45 patients were included with a total of 845 lesions. Mean GEFC/REFC ratios were 0.82 ± 0.10, 0.92 ± 0.11, 0.86 ± 0.10, and 1.09 ± 0.19 for birdshot chorioretinopathy, sarcoidosis, APMPPE, and PIC lesions, respectively, and were significantly different in repeated measures ANOVA (p < 0.0001). Non-pigmented retinal/choroidal lesions, macular neovascularizations, and fundus areas of choroidal thinning featured predominantly GEFC, and pigmented retinal lesions predominantly REFC. Color-FAF imaging revealed involvement of both, short- and long-wavelength emission fluorophores in posterior uveitis. The GEFC/REFC ratio of retinal and choroidal lesions was significantly different between distinct subgroups. Hence, this novel imaging biomarker could aid diagnosis and differentiation of posterior uveitis entities.

Evaluation of gallbladder mucosal changes about the type of stones in patients undergoing open cholecystectomy: A study of 184 patients

Background: Cholelithiasis is 7 times more frequent in North India, with an overall incidence of about 2–29%. The number and different morphology of gallstones can cause alterations in the gallbladder (GB) mucosa. GB mucosal change depends on the duration of cholelithiasis, size, number, type of stone, and the gender of the patient. The coexistence of gallstones with cholecystitis, hyperplasia, intestinal metaplasia, and carcinoma is well known in the literature. Incidental gallbladder (GB) carcinoma is revealed in 1% of all cholecystectomies done for benign conditions. The pathological stage of the disease decides the prognosis of the disease. Aims and Objectives: Gallstones are known to produce various histopathological changes in the GB. We aim to correlate gallstone characteristics such as (number and morphological type) with the type of mucosal response in the GB (inflammation, hyperplasia, metaplasia, and carcinoma). Materials and Methods: A study of gallstones was done in 184 cases of open cholecystectomies based on the histological changes. One hundred and sixty-five (89.95%) were associated with gallstones, and the rest 19 cases (10.05%) were of acalculous cholecystitis. The changes in the mucosa of the calculous GB (165 cases) were studied, and the correlation between the mucosal changes and the number and type of stones was evaluated. Tissue sections for histopathological studies were taken from the fundus, body, neck, and abnormal-looking areas of the GB. Results: A gender study revealed a higher incidence of inflammatory changes in males, while GB hyperplasia, intestinal metaplasia, and cancer were found only in females. Conclusion: Correlation of mucosal changes with a number, duration of disease, and morphological type of stones has suggested that there could be an association with the various GB mucosal changes such as inflammation, hyperplasia, metaplasia, and carcinoma of the GB.

Comparison of the Automated Pattern-Noise (PANO) Glaucoma Test with the HFA, an FDT Stimulus, and the Fundus Area Cup-to-disk Ratio.

Aim and objectiveTo compare the results of a new automated glaucoma test—Pattern–Noise (PANO)—to the Humphrey Visual Field Analyzer-II (HFA), the fundus area cup-to-disk ratio (CDR), and a frequency doubling technology (FDT) stimulus.Materials and methodsThis was a prospective study performed in the West-Region of Cameroon. Two hundred and nineteen eyes of 122 adult patients were included with a clinical suspicion of normal-tension or primary open-angle glaucoma and no other major ocular pathology. Eyes were examined with PANO, HFA (24-2 SITA standard), and FDT-stimulus in a randomized order followed by clinical assessment of the CDR.ResultsParametric correlation of the mean contrast threshold of PANO with the mean contrast threshold of FDT-stimulus, total deviation of HFA, and area CDR was 0.94, −0.85, and 0.62, respectively (p < 0.001 for all values). Spatial distribution of sensitivity thresholds is highly correlated (p < 0.001) at all points in the visual field between PANO and HFA. With cut-off values of 3 ± 1 dB for HFA mean deviation and 4 ± 1 for PANO mean contrast threshold and after eliminating borderline cases, PANO's sensitivity was 95% and specificity 60%. The mean patient age was 45.2 ± 15.8 years. Mean thresholds of PANO and FDT-stimulus decreased with increasing age. Mean examination time was 7.1 ± 1.8 minutes for PANO, 5.9 ± 1.3 minutes for HFA, and 4.7 ± 1.3 minutes for FDT-stimulus. The mean percentage of false-positives per examination was 4.95% for PANO, 4.62% (p = 0.025) for FDT-stimulus, and 2.10% for HFA.ConclusionThe results showed that PANO was successful in suspecting the presence of glaucoma. Pattern–Noise examination led to findings that were significantly correlated to HFA, FDT stimulus, and area CDR. Some patterns of defect were also correlated. Furthermore, PANO showed a reasonable examination time and error rate.Clinical significanceAffordable and robust visual field devices are lacking in large parts of the developing world. Comparing them to established methods is a prerequisite to their clinical use.How to cite this articleHannen T, El-Khoury S, Patel R, et al. Comparison of the Automated Pattern–Noise (PANO) Glaucoma Test with the HFA, an FDT Stimulus, and the Fundus Area Cup-to-disk Ratio. J Curr Glaucoma Pract 2021;15(3):132–138.

THE PLACE OF PROGRESSIVE SPECTACLES CORRECTION IN AN INTEGRATED APPROACH TO THE THERAPY OF THE EARLY STAGES OF AGE-RELATED MACULAR DEGENERATION

The purpose: to determine the place of progressive spectacles correction in an integrated approach for the treatment of early stages of age-related macular degeneration (AMD) in hyperopic patients. Material and methods: 30 patients (60 eyes) aged 42-75 y.o., average age (58,8 ± 6,5) years, with early stages of AMD and hyperopia were under observation. The observation group was represented by 20 patients (40 eyes). After AMD revealing they applied progressive spectacles correction of «universal» type and received orally dietary supplement Retinorm® 3 capsules one time per day. The comparison group consisted of 10 patients (20 eyes). They received the same oral dietary supplement and used the previous monofocal correction. Methods of examination of patients included: checking of visual acuity with correction, refractometry, tonometry, computer static perimetry, ophthalmobiomicroscopy with Goldmann lens, optical coherence tomography of the central fundus area with measurement of retinal thickness in the fovea zone and choroid in manual mode. The duration of observation in both groups was 4 months. Results. The thickness of the retina in the fovea zone after the use of correction and prescribed treatment did not change either in the observation group (p &gt; 0,1) or in the comparison group (p &gt; 0,1). The thickness of the choroid after the prescribed therapeutic measures significantly increased in the observation group (p &lt; 0,05) and remained without changes in the comparison group (p &gt; 0,1). An increase of visual acuity was established, as well as a decrease in the number of relative scotomas in the central part of the visual field both in the observation group (p &lt; 0,02) and in the comparison group (p &lt; 0,05). Conclusion. The use of «universal» type of progressive spectacles correction in combination with taking dietary supplement Retinorm® increases the effectiveness of treatment of early stages of AMD in hyperopic patients due to both the activation of choroidal blood circulation, and the improvement of metabolic processes in the choroid and retina.

Gastric Wall Thickness and Linear Staple Height in Sleeve Gastrectomy in Japanese Patients with Obesity.

Laparoscopic sleeve gastrectomy (LSG) is a standard procedure due to its low complication rates and favorable outcomes. However, limited data are available regarding the optimal size of linear staplers in relation to gastric wall thickness (GWT). Between August 2016 and December 2020, we performed LSG in 70 patients with an average age, body weight, and body mass index of 42years, 107kg, and 40kg/m2, respectively. We measured the GWT at the antrum, body, and fundus using resected specimens. We used an endo-linear stapler, and the closed staple height (CSH) was 1.75mm. We found that the average GWT at the antrum was significantly thicker than the GWT at the body and fundus. There was a statistically significant relationship between body weight and the GWT at the antrum and body and obstructive sleep apnea and the GWT at the body. The average CSH/GWT ratios were 0.55, 0.62, and 0.90 at the antrum, body, and fundus, respectively. However, in 20 patients (29%), the CSH/GWT ratio at the fundus area was ≥ 1.0, and only preoperative body weight was a significant predictor for a CSH/GWT ratio of ≥ 1.0. A light body weight may be related to a CSH/GWT ratio of ≥ 1.0 at the fundus.

Quantitative Assessment of Fundus Tessellated Density and Associated Factors in Fundus Images Using Artificial Intelligence.

PurposeThis study aimed to quantitative assess the fundus tessellated density (FTD) and associated factors on the basis of fundus photographs using artificial intelligence.MethodsA detailed examination of 3468 individuals was performed. The proposed method for FTD measurements consists of image preprocessing, sample labeling, deep learning segmentation model, and FTD calculation. Fundus tessellation was extracted as region of interest and then the FTD could be obtained by calculating the average exposed choroid area of per unit area of fundus. Besides, univariate and multivariate linear regression analysis have been conducted for the statistical analysis.ResultsThe mean FTD was 0.14 ± 0.08 (median, 0.13; range, 0–0.39). In multivariate analysis, FTD was significantly (P < 0.001) associated with thinner subfoveal choroidal thickness, longer axial length, larger parapapillary atrophy, older age, male sex and lower body mass index. Correlation analysis suggested that the FTD increased by 33.1% (r = 0.33, P < .001) for each decade of life. Besides, correlation analysis indicated the negative correlation between FTD and spherical equivalent (SE) in the myopia participants (r = −0.25, P < 0.001), and no correlations between FTD and SE in the hypermetropia and emmetropic participants.ConclusionsIt is feasible and efficient to extract FTD information from fundus images by artificial intelligence–based imaging processing. FTD can be widely used in population screening as a new quantitative biomarker for the thickness of the subfoveal choroid. The association between FTD with pathological myopia and lower visual acuity warrants further investigation.Translational RelevanceArtificial intelligence can extract valuable clinical biomarkers from fundus images and assist in population screening.

Changes in ghrelin, substance P and vasoactive intestinal peptide levels in the gastroduodenal mucosa of patients with morbid obesity

AimsThe aim of the study was to assess changes in levels of substance P (SP), vasoactive intestinal peptide (VIP) and ghrelin in the gastroduodenal mucosa of obese individuals, which has not been studied before. MethodsForty-six patients with a body mass index (BMI) of >40 kg/m2 and 20 patients with a BMI of 18–25 kg/m2 were included in the study. VIP and SP levels in the fundus, antrum and duodenal mucosa were measured in freshly frozen tissues using enzyme-linked immunosorbent assay (ELISA). Fasting levels of ghrelin in blood were also measured with ELISA. Tissue levels of ghrelin were assessed by immunohistochemical staining, and immunoreactivity scores were used for ghrelin evaluation in tissues. ResultsAntrum SP levels were higher in the obese group than in the control group. A significant number of obese patients had low VIP levels in the fundus and antrum. Intense ghrelin staining was observed in a limited number of cells in the mucosal area of the gastric fundus that was similar in the control and patient groups. In the antrum and duodenum, ghrelin staining was low in all the samples examined. ConclusionHere, we found that SP levels are increased, while VIP levels are decreased in the antrum of morbidly obese individuals. Previous studies show that SP increases gastroduodenal motility, that VIP slows it down, and that the gastric emptying rate is higher in obese individuals, preventing negative feedback mechanisms upon food intake. Therefore, increases in SP and decreases in VIP levels in the antrum may contribute to obesity by accelerating gastric emptying.

Evaluation of Gall Bladder Mucosal Changes in Relation to the Type of Stones in Patients Undergoing Laparoscopic Cholecystectomy: A Retrospective Study of 394 Patients

Background and Aim Gallbladder (GB) cancer is a highly fatal malignancy and approx. 10% new cases are diagnosed every year in India. The GB cancer has poor prognosis due to progressive nature. Understanding of risk factors that lead to GB development is urgently required for better management of the disease. Presence of stones in gall bladder generates varied mucosal reactions, which leads to different types of histopathological changes in mucosa. Here, our aim is to study the correlation between various types of mucosal responses e. g. inflammation, hyperplasia, metaplasia and carcinoma with different characteristics e. g. number and morphology of gallstones both in males and females. Materials and Methods A retrospective study of gallstones was performed on 438 cases of cholecystectomies operated laparoscopically based on the histological changes. Out of 438 cases, 394 (89.95%) were associated with gallstones and the rest 44 (10.05%) belonged to acalculous cholecystitis. The mucosal changes in calculous gall bladder were studied in 394 cases and its correlation with number and types of observed gallstones were evaluated. Tissue sections were taken from the fundus, body, neck and abnormal area of gallbladder for histopathological studies. Results Our study has revealed the higher incidence of inflammatory changes in males, while gall bladder hyperplasia, intestinal metaplasia and cancer cases were found mostly in females. Conclusion Our study showed that changes in the number and morphology of gallstones are directly associated with the mucosal changes in gallbladder e.g. inflammation, hyperplasia, metaplasia and gall bladder carcinoma

Validation of quantitative assessment of indocyanine green fluorescent imaging in a one-vessel model.

Evaluation of intestinal perfusion remains subjective and depends on the surgeon´s individual experience. Intraoperative quality assessment of tissue perfusion with indocyanine green (ICG) fluorescence using a near-infrared camera system has been described in different ways and for different indications. The aim of the present study was to evaluate fluorescent imaging (FI) in the quantitative assessment of intestinal perfusion in a gastric tube model in pigs and to compare the results to results obtained with florescent microspheres (FM), the gold standard for tissue perfusion. Seven pigs (56.0±3.0 kg), both males and females, underwent gastric tube formation after transection and ligation of the gastric arteries, except the right gastroepiploic artery, to avoid collateral blood flow. After baseline assessment (T0), hypotension (T1) was induced by propofol (Karampinis et al 2017) (< 60 mmHg). Then, propofol was paused to obtain normotension (T2, Mean arterial pressure (MAP) 60-90 mmHg). Finally, hypertension (T3, MAP>90 mmHg) was induced by norepinephrine. Measurements were performed in three regions of interest (ROIs) under standardized conditions: the fundus (D1), corpus (D2), and prepyloric area (D3). Hemodynamic parameters and transit-time flow measurement (TTFM) in the right gastroepiploic artery were continuously assessed. FI, FM and the partial pressure of tissue oxygen (TpO2) were quantified in each ROI. The study protocol could successfully be performed during stable hemodynamics. Flow in the gastroepiploic artery measured by transit time flow measurement (TTFM) was related to hemodynamic changes between the measurements, indicating improved blood flow with increasing MAP. The distal part of the gastric tube (D1) showed significantly (p<0.05) impaired perfusion compared to the proximal parts D3 and D2 using FM. ICG-FI also showed the highest values in D3 and the lowest values in D1 at all hemodynamic levels (T1-T3; p<0,05). Visual and quantitative assessment of gastric tube perfusion is feasible in an experimental setting using ICG-FI. This might be a promising tool for intraoperative assessment during visceral surgery in the future.

Pseudoxanthoma Elasticum.

CASE REPORT A 57-year-old man presented to the emergency department for evaluation of hematemesis. Physical examination was notable for complete blindness and 2–3 mm yellow papules with increased density around the neck, antecubital area, popliteal fossa, axillary folds, and periumbilicus (Figure 1). An esophagogastroduodenoscopy was scheduled, which revealed fresh blood in the fundus with several large clots in the stomach, limiting further visualization (Figure 2). Subsequent angiography revealed active multifocal hemorrhage along the path of the proximal left gastric artery which was embolized (Figure 3). However, within 3 hours, the patient began to bleed once more. The general surgery team was consulted, but on learning from the patient's wife that he had a previously undisclosed diagnosis of pseudoxanthoma elasticum (PXE), operative management was deferred. A second angiography revealed no new bleeding vessels, but the right gastric artery was empirically coiled. The patient tolerated the procedure well, continuing to remain stable with steady improvement in his hemoglobin. Five days after admission, the patient made a full recovery and was discharged home.Figure 1.: Physical examination noting yellow, irregularly shaped papules, 2–3 mm in size coalescing into plaques around (A) the neck, (B) the antecubital area, and (C) the popliteal fossa.Figure 2.: A large clot in the fundus area of the stomach as visualized by endoscopy.Figure 3.: Angiography revealing (A) bleeding in the proximal left gastric artery with (B) successful coiling.Pseudoxanthoma elasticum is an inherited multisystem connective tissue disorder that results in fragmentation and calcification of elastic fibers. Over 80% of affected individuals present with 2–10 mm sized yellow skin papules with a predilection for the neck and flexural areas.1 PXE also causes gastrointestinal (GI) hemorrhage in approximately 13% of affected individuals, which occurs because of degeneration of arterial elastic fibers in the mucosa of the stomach and intestine.2 Early recognition and diagnosis of PXE-associated GI bleeding can lead to improved outcomes because the bleeding in this patient population is usually recurrent and life-threatening.1 However, because the GI manifestations of PXE are uncommon, the underlying diagnosis is frequently missed. In cases where PXE is suspected, a skin examination with particular attention to the neck and flexural areas is crucial.1 Ophthalmologic manifestations of PXE are also an identifiable sign of the disease, and a fundal examination looking for angioid streaks or choroidal neovascularization in those with suspected vascular involvement should be performed.3 Other vascular signs such as intermittent claudication in all extremities and peripheral artery disease can be seen secondary to dystrophic mineralization of connective tissue.1,4,5 Therefore, a detailed extremity and cardiovascular examination should be conducted in all patients suspected of having PXE. DISCLOSURES Author contributions: All authors contributed equally to this manuscript. S. Qian is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

Fundus Autofluorescence Lifetimes and Spectral Features of Soft Drusen and Hyperpigmentation in Age-Related Macular Degeneration.

PurposeTo investigate the autofluorescence lifetimes as well as spectral characteristics of soft drusen and retinal hyperpigmentation in age-related macular degeneration (AMD).MethodsForty-three eyes with nonexudative AMD were included in this study. Fluorescence lifetime imaging ophthalmoscopy (FLIO), which detects autofluorescence decay over time in the short (SSC) and long (LSC) wavelength channel, was performed. The mean autofluorescence lifetime (τm) and the spectral ratio (sr) of autofluorescence emission in the SSC and LSC were recorded and analyzed. In total, 2760 soft drusen and 265 hyperpigmented areas were identified from color fundus photographs and spectral domain optical coherence tomography (SD-OCT) images and superimposed onto their respective AF images. τm and sr of these lesions were compared with fundus areas without drusen. For clearly hyperfluorescent drusen, the local differences compared to fundus areas without drusen were determined for lifetimes and sr.ResultsHyperpigmentation showed significantly longer τm (SSC: 341 ± 81 vs. 289 ± 70 ps, P < 0.001; LSC: 406 ± 42 vs. 343 ± 42 ps, P < 0.001) and higher sr (0.621 ± 0.077 vs. 0.539 ± 0.083, P < 0.001) compared to fundus areas without hyperpigmentation or drusen. No significant difference in τm was found between soft drusen and fundus areas without drusen. However, the sr was significantly higher in soft drusen (0.555 ± 0.077 vs. 0.539 ± 0.081, P < 0.0005). Hyperfluorescent drusen showed longer τm than surrounding fundus areas without drusen (SSC: 18 ± 42 ps, P = 0.074; LSC: 16 ± 29 ps, P = 0.020).ConclusionsFLIO can quantitatively characterize the autofluorescence of the fundus, drusen, and hyperpigmentation in AMD.Translational Relevance The experimental FLIO technique was applied in a clinical investigation. As FLIO yields information on molecular changes in AMD, it might support future diagnostics.

The Role of Head Elevation in Treatment of Vitreous Haemorrhage.

ObjectiveTo investigate the effect of head elevation on macular clearance of acute vitreous haemorrhage.DesignCrossover, prospective, randomized clinical study.SettingUniversity, tertiary care hospital.Participants24 vitreous haemorrhage patients, average age 55 years.MethodsPatients with acute vitreous haemorrhage who were randomly separated into 2 groups. In group A, the patients were assigned normal head position for the first week of sleep, then switched to head elevation for the second week (n=12). In group B, the patients were assigned the head position in reverse order (n=12). A washout period of 24 hrs was used between treatments. The carryover, sequence, and treatment effects were analysed by using various mixed models.OutcomesBest-corrected visual acuity (BCVA), vitreous haemorrhage grading, fundus photo colour intensity, and self-assessment scores.ResultsAlthough the mean BCVA (LogMAR) change following head elevation was higher than following normal head position, the difference was not statistically significant (−0.053 and 0.065 LogMAR, respectively, p = 0.2). Vitreous haemorrhage grading in the central region showed no statistical improvement in either group. Fundus photo colour intensity comparison in all fundus areas also showed no statistically significant differences in either group.ConclusionAlthough head elevation is recommended to patients with acute vitreous haemorrhage, this study showed no statistically significant improvement in BCVA, vitreous haemorrhage grading, or fundus photo colour intensity between head elevation and normal head position in the early observation period.Trial registration: TCTR20150314001.