Michael Gaynon, MD

Abstract

Importance: Previous studies of myo-inositol in preterm infants with respiratory distress found reduced severity of retinopathy of prematurity (ROP) and less frequent ROP, death, and intraventricular hemorrhage. However, no large trials have tested its efficacy or safety.Objective: To test the adverse events and efficacy of myo-inositol to reduce type 1 ROP among infants younger than 28 weeks' gestational age.Design, Setting, and Participants: Randomized clinical trial included 638 infants younger than 28 weeks' gestational age enrolled from 18 neonatal intensive care centers throughout the United States from April 17, 2014, to September 4, 2015; final date of follow-up was February 12, 2016. The planned enrollment of 1760 participants would permit detection of an absolute reduction in death or type 1 ROP of 7% with 90% power. The trial was terminated early due to a statistically significantly higher mortality rate in the myo-inositol group.Interventions: A 40-mg/kg dose of myo-inositol was given every 12 hours (initially intravenously, then enterally when feeding; n=317) or placebo (n=321) for up to 10 weeks.Main Outcomes and Measures: Type 1 ROP or death before determination of ROP outcome was designated as unfavorable. The designated favorable outcome was survival without type 1 ROP.Results: Among 638 infants (mean, 26 weeks' gestational age; 50% male), 632 (99%) received the trial drug or placebo and 589 (92%) had a study outcome. Death or type 1 ROP occurred more often in the myo-inositol group vs the placebo group (29% vs 21%, respectively; adjusted risk difference, 7% [95% CI, 0%-13%]; adjusted relative risk, 1.41 [95% CI, 1.08-1.83], P=.01). All-cause death before 55 weeks' postmenstrual age occurred in 18% of the myo-inositol group and in 11% of the placebo group (adjusted risk difference, 6% [95% CI, 0%-11%]; adjusted relative risk, 1.66 [95% CI, 1.14-2.43], P=.007). The most common serious adverse events up to 7 days of receiving the ending dose were necrotizing enterocolitis (6% for myo-inositol vs 4% for placebo), poor perfusion or hypotension (7% vs 4%, respectively), intraventricular hemorrhage (10% vs 9%), systemic infection (16% vs 11%), and respiratory distress (15% vs 13%).Conclusions and Relevance: Among premature infants younger than 28 weeks' gestational age, treatment with myo-inositol for up to 10 weeks did not reduce the risk of type 1 ROP or death vs placebo. These findings do not support the use of myo-inositol among premature infants; however, the early termination of the trial limits definitive conclusions.

View details for PubMedID 30357297

View details for DOI 10.1038/s41372-018-0177-9

View details for Web of Science ID 000446499400003

View details for Web of Science ID 000442912508080

View details for PubMedID 29547455

View details for DOI 10.1038/eye.2017.29

View details for PubMedID 28282059

Abstract

Niacin, a treatment for dyslipidemia, is known to induce vasodilation as a secondary effect. Previous instances of patients with chronic central retinal vein occlusion (CRVO) and cystoid macular edema (CME) have been observed to spontaneously improve when placed on systemic niacin for hypercholesterolemia. The purpose of this study was to evaluate the effects of niacin on CRVO and associated ocular complications.A prospective, single-center, non-randomized, interventional case series of niacin for CRVO was conducted. Best-correct visual acuity (BCVA), central macular thickness (CMT), and ocular complications were analyzed in 50 patients over 1year. Eight patients were controls.The mean initial logMAR BCVA was 0.915, and improved with niacin to 0.745 (P=0.12), 0.665 (P=0.02) and 0.658 (P=0.03) after 3, 6, and 12months of follow-up, respectively. At baseline, mean CMT was 678.9m, and improved to 478.1m (P=0.001), 388.6m (P<0.001), and 317.4m (P<0.001) for the same time points. The control group had a mean initial logMAR BCVA of 1.023, which gradually deteriorated to 1.162 (P=0.36) after 12months, and baseline CMT of 700.0m at baseline, which gradually improved to 490.9m (P=0.06) after 12months. Panretinal photocoagulation for neovascularization was required in 5 patients (13.2%) receiving niacin and 3 (37.5%) controls.These data suggest that niacin may be associated with functional and anatomic improvements in eyes with CRVO. Future investigations will help ascertain whether there is a role for niacin as an adjunct therapy to intravitreal injections in the management of CRVO.

View details for DOI 10.1007/s00417-017-3606-0

View details for PubMedID 28161829

View details for DOI 10.1001/jamaophthalmol.2016.1028

View details for PubMedID 27227881

Abstract

The authors present the first case of peripheral avascular retina in a term male neonate with pancreatic exocrine insufficiency, atypical microvillus inclusion disease, flat tympanograms, and recurrent urinary tract infections. Clinical examination showed avascular peripheral retina to posterior zone II temporally, with a flat stage 1-like demarcation line, and no plus disease. Genetic testing results were normal. The patient developed peripheral neovascularization and underwent panretinal photocoagulation. This case likely represents mild Norrie disease, familial exudative vitreoretinopathy, or incontinentia pigmenti due to a Wnt signaling abnormality. While these conditions are usually more severe, a variable spectrum of Wnt abnormalities exists throughout the body.

View details for DOI 10.3928/23258160-20150521-14

View details for Web of Science ID 000359292500014

View details for PubMedID 26057766

Abstract

The purpose of this study was to report a case of an impending central retinal artery occlusion with hypoperfusion in a moyamoya patient.A young, surgically revascularized moyamoya patient experienced severe unilateral vision loss from 20/25 to hand motions because of impending central retinal artery occlusion. The patient was treated with a combination of intermittent ocular massage, intraocular pressure-lowering medications, and aspirin.A case of a moyamoya patient at Stanford University Medical Center.Visual acuity was restored to baseline by improving the ocular arterial-venous gradient after prompt administration of ocular massage, intraocular pressure-lowering drops, and aspirin.This dramatic result suggests that, if performed in a timely manner, augmentation of ocular perfusion can result in complete restoration of vision in some cases of incipient central retinal artery occlusion.

View details for DOI 10.1097/ICB.0b013e31828eef20

View details for PubMedID 25391116

Abstract

The purpose of this study was to report a case of a chorioretinal coloboma mimicking a second optic disk in an asymptomatic 12-year-old boy.This is a case report.An asymptomatic 12-year-old boy presented with a chorioretinal coloboma of the right eye giving the impression of a second optic disk. The patient also had a superior visual field defect.True optic nerve duplication is a rare entity that can be mimicked by other etiologies, including choroidal colobomas and postinflammatory lesions, requiring careful examination by clinicians.

View details for DOI 10.1097/ICB.0b013e3181cc2135

View details for PubMedID 25389885

Abstract

Hairy cell leukemia (HCL) is a rare disorder that occasionally has visual symptoms after diagnosis. The authors present a case of HCL in which bilateral visual symptoms led to the initial diagnosis.Observational case report.Bilateral decreased vision to 20/30 in the right eye and 20/40 in the left due to intraretinal and preretinal hemorrhages with no other systemic signs or symptoms prompted a hematologic evaluation in which HCL was found to be the causative disorder in a previously healthy 41-year-old man.The authors present a rare case in which bilateral visual complaints led to the diagnosis of HCL. Thus, though uncommon, HCL should be considered in the differential diagnosis of otherwise unexplained retinal hemorrhages.

View details for PubMedID 19253258

View details for Web of Science ID 000248115100010

View details for PubMedID 17634454

Abstract

To review systemic modifiable factors that might downregulate pathologic levels of vascular endothelial growth factor (VEGF) in prethreshold retinopathy of prematurity (ROP), and thereby reduce the risk of blindness in affected infants.Review of the author's clinical experience as compared to the STOP-ROP study, and discussion and literature review of the potential effects of oxygen supplementation, light adaptation state, and correction of severe anemia on the course of prethreshold retinopathy of prematurity (ROP).Moderate oxygen supplementation, combined with light adaptation to reduce retinal oxygen consumption and correction of severe anemia, were associated, in the author's experience, with improvement in the clinical course of prethreshold ROP. Withdrawal of these measures was often associated with deterioration of ROP.Systemic measures can be taken that may reduce the risk of blindness in infants with prethreshold ROP. For those infants who require laser treatment for threshold ROP, prior efforts to moderate excessive levels of VEGF may improve the chances of a successful surgical result, by slowing the momentum of the disease.

View details for Web of Science ID 000247086400006

View details for PubMedID 16946672

View details for Web of Science ID 000168392103638

Abstract

To report an unusual case of diffuse retinal hemorrhage associated with strangulation in a neonate with a tightly wrapped nuchal cord around his neck at birth who was noted to have eyelid and subconjunctival petechial hemorrhages upon delivery.Clinical diagnostic examination as well as postmortem gross and histopathologic examination of ocular and central nervous system structures was performed.Funduscopic and gross pathologic examination of the eyes revealed extensive unilateral retinal hemorrhage of the right eye only. This was corroborated by histopathologic studies, which revealed unilateral diffuse hemorrhage throughout all nuclear layers of the retina with a particularly dense nerve fiber layer and sub-internal limiting membrane hemorrhage in the macula along with extraocular muscle and episcleral hemorrhage. Clinical, gross, and microscopic examination also revealed multiple areas of hemorrhage involving the right side of the brain and throughout the cerebellum.Although retinal findings in nonaccidental trauma are common, accidental strangulation retinopathy in neonates is a rare occurrence. To the authors' knowledge, this case is the only documented histopathologic study of hemorrhagic retinopathy associated with strangulation in the literature.

View details for Web of Science ID 000169241600010

View details for PubMedID 11421016

View details for Web of Science ID 000085106500032

View details for PubMedID 10654965

Abstract

The optimum level of oxygen saturation for infants with prethreshold retinopathy of prematurity (ROP) is unknown. We reviewed our conversion rate from prethreshold to threshold ROP between 1985 and 1993 during which time target levels of oxygen saturation rose in a stepwise fashion. A retrospective study of 153 infants with prethreshold ROP was performed at Stanford University between 1985 and 1993 that showed that target minimum oxygen saturation rose from 92% (1985-1987) to 95% (1988) to 96% (1989) to 99% (1990-1993). In addition, we looked at 26 infants between 1994 and 1996 who were excluded from the STOP-ROP study and who were not receiving supplemental oxygen in an effort to maintain equipoise for that study. Infant characteristics were tabulated, and rates of progression from prethreshold to threshold ROP were calculated. Rates of progression to threshold varied little between 1985 and 1989 (average 37%), but dropped to 7% for the period between 1990 and 1993. From 1994 through 1996 the rate of progression to threshold disease rose again, to 38%. Moderate supplemental oxygen (target saturation 99% with PO2 no higher than 100 mm Hg) was associated with regression of prethreshold ROP, without appearing to arrest retinal vascular maturation.

View details for PubMedID 9447528

View details for Web of Science ID A1992HK13501947

View details for Web of Science ID A1991FC76201056

Abstract

Bacteroides fragilis is an infrequent anaerobic ocular pathogen. Nevertheless, this organism is of particular significance because it may be resistant to many antibiotics that are typically effective against anaerobes. We present what is to the best of our knowledge the first reported case of B. fragilis endophthalmitis. The endophthalmitis presented in a 95-year-old man following extracapsular cataract extraction with posterior chamber intraocular lens implantation.

View details for PubMedID 2191760

Abstract

Retinopathy of prematurity has reappeared in the neonatal nursery after largely disappearing 35 years ago. The major factor in its reemergence is the progressive improvement in neonatal care, resulting in salvage of infants who formerly would have been lost. Oxygen is now recognized to be but one of many interacting factors in the development of retinopathy of prematurity, with extreme immaturity being the primary factor. Methods of examination, classification and treatment of retinopathy of prematurity are discussed.

View details for PubMedID 2194177

View details for Web of Science ID A1989R585101188

Abstract

We examined two children with presumed shaken baby syndrome. Both children suffered severe, indirect closed head trauma with intracranial hemorrhage, sharply increased intracranial pressure, and extensive neurologic damage. In addition to extensive retinal and preretinal hemorrhages, bilateral symmetric white ring-shaped retinal folds were seen encircling the macula outside the vascular arcades. These retinal folds may be a hallmark of shaking injuries in child abuse victims.

View details for PubMedID 3177559

Abstract

Clinical neurophysiologists may be asked to participate in the evaluation of patients with injured eyes. We describe a method for eliciting evoked potentials of cerebral origin using electrical pulse stimuli delivered to the globe of the eye through a contact lens electrode mounted on the cornea. These visual electrical evoked potentials (VEEPs) are contrasted with conventional flash visual evoked potentials in normal subjects and in 19 eyes of 17 patients with severe ocular damage, mostly recent trauma. The findings suggest that the site of transcorneal electrical excitation is not the photoreceptors, but more likely one of the nerve cell layers of the retina. VEEP recordings offer a way to circumvent the opacification of the ocular media by blood, which may otherwise hamper the evaluation of retinal function in the injured eye. Preserved VEEP response does not necessarily predict the capacity to recover visual function. Absent VEEP response is an unfavorable prognostic sign, which may be considered in arriving at a decision about enucleation.

View details for Web of Science ID A1987F561100021

View details for PubMedID 3796828

Abstract

A further subdivision of functions during vitrectomy surgery has been enabled. By means of a separate, suture-secured fiberoptic endoilluminator and a modified infusion cannula located in the inferior quadrants, two superior sclerotomies are kept free for the use of a variety of simple and complex instruments, alone or in combination. Included among these are vitreous scissors, forceps, picks, spatulas, diathermy probes, and endophotocoagulators.

View details for Web of Science ID A1986D042900041

View details for PubMedID 3729782

Abstract

Macular photocoagulation requires precise localization of abnormalities to be treated, in order to accomplish the aims of therapy without unnecessarily damaging adjacent tissue. A method is described by which a color fundus photo or a fluorescein image can be projected through a beam splitter into the ocular of a laser slit lamp, thus affording an image congruent with the surgeon's view of the patient's macula.

View details for Web of Science ID A1984SG02800026

View details for PubMedID 6703999

Abstract

Four patients, including three with the acquired immunodeficiency syndrome (AIDS), were treated with high-dose, buffy coat-derived alpha-interferon for progressive cytomegalovirus retinitis. Two of these patients had decreased viruria during therapy and the other two had increased viruria. There was evidence of progression of disease despite therapy in all patients, although the retinitis eventually became quiescent in the patient without AIDS. The severe immunosuppression encountered in AIDS patients complicates the management of cytomegalovirus and other opportunistic infections.

View details for Web of Science ID A1984RY30400007

View details for PubMedID 6322678

View details for PubMedCentralID PMC185427

Abstract

Retinal neovascularization, a rare complication of ocular toxoplasmosis, is a source of vitreous hemorrhage. We examined three patients (all women, 70, 36, and 19 years old) with inactive toxoplasmosis scars associated with occlusion of a retinal arteriole or venule passing through the scar, capillary nonperfusion, and adjacent retinal neovascularization. In two patients photocoagulation of the ischemic areas produced a cessation of hemorrhage and the disappearance of neovascularization. In the third case, the neovascular frond was avulsed from its supplying retinal arteriole without treatment.

View details for Web of Science ID A1984TS83000008

View details for PubMedID 6208784

View details for Web of Science ID A1983PU88600671

Abstract

A 56-year-old man sustained an intraocular injury by a piece of steel followed by endophthalmitis, which resolved after lensectomy, vitrectomy, and intravitreal injections of gentamicin. Acinetobacter anitratus was the organism responsible for the endophthalmitis. It is a Gram-negative polymorphic organism that can resemble several other pathogens and possesses unpredictable antibiotic susceptibility. A. anitratus is an important cause of nosocomial infection but has not previously been reported as a cause of endophthalmitis following trauma.

View details for Web of Science ID A1983PY70700011

View details for PubMedID 6600400

View details for PubMedCentralID PMC1039980

Abstract

Dynamic ultrasonic imaging adds a time dimension to the clinical diagnosis of ocular pathology. A recent development in this area of ophthalmic sonography has been the introduction of an electronically scanned, multiple transducer system that provides improved real-time imaging of ocular tissue motion. This paper discusses clinical observations made in a variety of ophthalmic conditions with a high speed, linear array ultrasound system and discusses briefly the apparatus and special examination techniques needed to make these observations. Clinical subjects include vitreo-retinal adhesions: the clear cortical vitreous network; vitreous hemorrhage, opacities and membranes; shallow, fixed, and mobile retinal detachments; blood vessels within ocular tumors and the evaluation of intraocular foreign bodies.

View details for Web of Science ID A1983QM43200012

View details for PubMedID 6866450

Abstract

Thirty individuals with the clinical diagnosis of Down's syndrome received ophthalmologic examination periodically over 10 years at a state school for exceptional children. External examination, retinoscopy, anterior segment evaluation, ophthalmoscopy, and tonometry were usually done. The ages at present range from 10 to 50 years. The sex ratio was 80% male and 20% female. Three subjects died during the course of the study. The most frequent ocular anomalies were oblique fissures, refractive error, blepharoconjunctivitis, epicanthus, and Brushfield's spots. All of these occurred in 50% or more of the subjects.

View details for Web of Science ID A1977EH12400001

View details for PubMedID 147042