Poorab K. Sangani

STUDY DESIGN: Retrospective review of a large series of patients who underwent spinal surgery at a single institution during a 10-year period. OBJECTIVES: To further clarify the frequency of incidental durotomy during spine surgery, its treatment, associated complications, and results of long-term clinical follow-up. SUMMARY OF BACKGROUND DATA: Incidental durotomy is a relatively common occurrence during spinal surgery. There remains significant concern about it despite reports of good associated clinical outcomes. There have been few large clinical series on the subject. METHODS: A retrospective review was conducted of clinical and surgical records and radiographic data for consecutive patients who underwent spinal surgery performed by the two senior surgeons from January 1989 through December 1998. RESULTS: A total of 2144 patients were reviewed, and 74 were found to have dural tears occurring during or before surgery. Incidental durotomy occurred at the time of surgery in 66 patients (3.1% overall incidence). Incidence varied according to the specific procedure performed but was highest in the group that underwent revision surgery. The incidence of clinically significant durotomies occurring during surgery but not identified at the time was 0.28%. All dural tears that occurred during surgery and were recognized (60 of 66) were repaired primarily. Pseudomeningoceles developed in five of the remaining six patients. All six patients had subsequent surgical repair of dural defects because of failure of conservative therapy. A mean follow-up of 22.4 months was available and showed good long-term clinical results for all patients. CONCLUSIONS: Incidental durotomy, if recognized and treated appropriately, does not lead to long-term sequelae.

OBJECTIVE: To correlate 3 common presenting signs of retinoblastoma with patient and ocular survival and to assess the efficacy of current pediatric screening practices for retinoblastoma. METHODS: A retrospective study was conducted of 1831 retinoblastoma patients from our center (1914-June 2000). Patient survival (excluding deaths from other primary neoplasms) and ocular survival (presenting eyes) rates were calculated and analyzed using the Kaplan-Meier method. RESULTS: Leukocoria correlated with excellent patient survival (>86%, 5 years) but poor ocular survival in unilateral (4%, 5 years) and bilateral patients (29%, 5 years). A total of 308 (19%) of 1654 patients presented with strabismus: patient survival was excellent (90%, 5 years), and ocular survival was poor (17%, 5 years) yet better than leukocoria. Patients who had a family history of retinoblastoma and were clinically screened for retinal tumors from birth were diagnosed younger (8 months of age) and earlier (Reese Ellsworth group 1 = 26 [58%] of 45) and had better ocular survival than nonscreened patients with a family history. More patients were initially detected by family/friends (1315 [80%] of 1632) than pediatricians (123 [8%] of 1632) or ophthalmologists (156 [10%] of 1632). CONCLUSION: Most US children whose retinoblastoma is diagnosed initially present with leukocoria detected by a parent, despite routine pediatric screening for leukocoria via the red reflex test. Initial disease detection at the point of leukocoria or strabismus correlated with high patient survival rates and poor ocular survival rates for the presenting eye. Saving eyes and vision requires disease recognition before leukocoria, as demonstrated by the better ocular salvage rate among patients who had a positive family history and received clinical surveillance via early, routine dilated funduscopic examinations by an ophthalmologist.

Purpose: To investigate the association of genetically determined primary open-angle glaucoma (POAG), myopic refractive error (RE), type 2 diabetes (T2D), blood pressure (BP), body mass index (BMI), cigarette smoking, and alcohol consumption with the risk of age-related cataract. Methods: To assess potential causal effects of clinical or behavioral factors on cataract risk, we conducted two-sample Mendelian randomization analyses. Genetic instruments, based on common genetic variants associated with risk factors at genome-wide significance (P < 5 × 10-8), were derived from published genome-wide association studies (GWAS). For age-related cataract, we used GWAS summary statistics from our previous GWAS conducted in the Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort (28,092 cataract cases and 50,487 controls; all non-Hispanic whites) or in the UK Biobank (31,852 cataract cases and 428,084 controls; all European-descent individuals). We used the inverse-variance weighted (IVW) method as our primary source of Mendelian randomization estimates and conducted common sensitivity analyses. Results: We found that genetically determined POAG and mean spherical equivalent RE were significantly associated with cataract risk (IVW model: odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.08; P = 0.018; per diopter more hyperopic: OR = 0.92; 95% CI, 0.89-0.93; P = 6.51 × 10-13, respectively). In contrast, genetically determined T2D, BP, BMI, cigarette smoking, or alcohol consumption were not associated with cataract risk (P > 0.05). Conclusions: Our results provide evidence that genetic risks for POAG and myopia may be causal risk factors for age-related cataract. These results are consistent with previous observational studies reporting associations of myopia with cataract risk. This information may support population cataract risk stratification and screening strategies.

PURPOSE: To evaluate the safety and efficacy of trabeculectomies performed by ophthalmology residents at a metropolitan county hospital, under the supervision of attending physicians. METHODS: A retrospective analysis of resident-performed trabeculectomies at the San Francisco General Hospital from the period of 1994 to 2004 was performed. The preoperative and postoperative ocular data of 50 eyes in 35 patients were evaluated. Of the 50 cases, 47 procedures were performed as primary trabeculectomies and 3 were revisions of trabeculectomies. RESULTS: The average follow-up period was 28.9+/-17.6 months with an intraocular pressure (IOP) decrease from 23.2+/-9.4 mm Hg preoperatively to 11.3+/-4.4 mm Hg at last follow-up, for a mean reduction of 11.9+/-10.5 mm Hg (51.6%) (P<0.0001). Follow-up periods ranged from 3 months to over 6 years. The number of medications required decreased from 3.2+/-1.1 to 0.6+/-0.1 (P<0.0001). Success, defined by a postoperative IOP < or =21 mm Hg or a decreased postoperative IOP of at least 25% from preoperative pressure if the preoperative IOP was already < or =21 mm Hg, was observed in 42 eyes (84%) at last follow-up. Best-corrected visual acuity was stable or improved in 22 eyes (44%) and was noted to decrease 2 or more Snellen lines in 28 eyes (56%). Notable complications included 3 cases (6%) of persistent hypotony (IOP<5), 1 case (2%) of late endophthalmitis, and 1 case (2%) of phthisis. Seven eyes (14%) required subsequent penetrating glaucoma procedures due to bleb failure. CONCLUSIONS: Results of this study suggest that the outcomes of trabeculectomies performed by residents at a county hospital can have a high success rate, comparable with previous studies in the literature. Rates of complications are overall similar to those found in the published literature.

Two patients, ages 72 and 71, who underwent lumbar decompressive surgery for spinal stenosis, were evaluated for postoperative sudden sensorineural hearing loss (SSHL). After two uncomplicated spinal procedures, both patients developed SSHL immediately after surgery. Hearing loss was moderate to profound in these two patients. None of the patients had a significant otologic history. Nitrous oxide administration, Valsalva maneuvers during general anesthesia, and transient drops in cerebrospinal fluid pressure stemming from spinal decompression may, in some combination, lead to an implosive force on the inner ear, causing SSHL. Further causes of postlumbar surgery SSHL may include microemboli or viral infections. SSHL is a rare but possible complication after nonotologic, noncardiac bypass surgery; only 26 cases of SSHL after this surgery have been reported. We encourage the continued reporting of sudden sensorineural hearing loss after spinal surgery.