‘Progressive peripheral anterior synechiae in iridocorneoendothelial syndrome- a crawling disaster’

Purpose Iridocorneal endothelial (ICE) syndrome is well known to cause refractory glaucoma in young adults. Commonly acclaimed mechanism for trabeculectomy failure in these cases include accelerated subconjunctival fibrosis, abnormal endothelial proliferation, and closure of ostium. In the following article, we present a case of Iridocorneal endothelial syndrome that presented with refractory glaucoma after trabeculectomy due to rapidly progressive peripheral anterior synechiae causing angle closure and corneal decompensation that mandated a tailored surgical approach of management. Methods: This is a descriptive case report based on electronic medical records, patient observation, surgical intervention, and follow-ups. Case description: A thirty-eight-year-old-male presented to us with signs suggestive of iridocorneal endothelial syndrome with gonioscopy revealing peripheral anterior synechiae (PAS) over four clock-hours temporally. Uncontrolled intraocular pressure (IOP) despite maximal medical therapy mandated augmented trabeculectomy with anti-fibrotics. The bleb failed within 3 weeks of trabeculectomy, with evidence of progressive crawling PAS causing endothelial decompensation and raised IOP. He underwent Ahmed glaucoma valve (AGV) implant surgery with viscosynechiolysis and sectoral iridectomy under antiviral cover. This helped control IOP and retain corneal clarity, with no recurrence of PAS in the affected area. Conclusion: Progressive peripheral synechiae in ICE syndrome can cause early bleb failure and refractory glaucoma. Careful viscosynechiolysis and sectoral iridectomy alongside a second implant surgery can help salvage visual functions and preserve corneal clarity while preventing further progression of PAS in these eyes.

Primary laryngeal lymphoma: a diagnostic challenge

<p class="abstract">Lymphomas of head and neck constitute 5-15% of malignancies in this region. However, its primary occurrence at the larynx is exceedingly rare due to the paucity of lymphoid tissue. Here, we reported a case of a 41 year old male who presented with a 1 month history of hoarseness and odynophagia. The examination revealed right vocal cord palsy and an ipsilateral subglottic exudate, that was misdiagnosed as infectious disease. The lesion quickly progressed to airway obstruction, requiring a tracheotomy. Multiple biopsies under general anesthesia were needed before reaching the final diagnosis of diffuse large B-cell lymphoma, Epstein-Barr positive. Selected treatment modality included 3 cycles of chemotherapy followed by radiotherapy in moderate dose with complete remission after 2 years of follow up. The tracheotomy was removed, however, the patient did not recover vocal quality. This case highlighted the heterogeneous presentation of extra-nodal head and neck lymphomas and emphasized the need for suspicion of neoplasm when an infection doesn’t respond to maximal medical therapy.</p>

Endoscopic posterior nasal neurectomy for intractable rhinitis: a systematic review of the literature Running Title: Endoscopic PNN: a systematic review

Objectives: Rhinitis affects up to 40% of the population worldwide and can significantly reduce quality of life. Some patients remain symptomatic despite maximal medical therapy. In refractory cases, posterior nasal neurectomy (PNN - the division of the intranasal nerve branches containing postganglionic parasympathetic fibres) is postulated to reduce symptom burden. The objectives of this paper were to review the literature to establish whether the procedure is effective and safe in the management of allergic and non-allergic rhinitis. Design: A systematic review of Pubmed, EMBASE and MEDLINE was undertaken. Studies were excluded if not available in English or undertaken in non-human subjects. Participants: Seventeen articles satisfied the inclusion criteria studying in total 2029 patients. Sample size ranged from 8-1056. Main Outcome Measures: Patient-reported objective and subjective outcomes and post-operative complications were reviewed Results: There were two randomised controlled trials, two case control studies, and the remaining thirteen were case series using both objective and subjective outcome measures. All but one study found improved patient reported outcomes following PNN. Complications were reported in 10 studies - haemorrhage was the most common complication and was observed in 28 patients (1.6% of subjects). Conclusions: Endoscopic posterior nasal neurectomy is safe and appears to be effective in the treatment of intractable rhinitis but the level of the available evidence was generally poor. Larger, well designed studies are needed to clarify its role in the management of difficult-to-treat rhinitis.

Intracranial Atherosclerotic Disease

Purpose of the ReviewThis article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery.Recent FindingsData from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT.SummaryICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.

Abstract 1122‐000095: Revisiting the Role of Angioplasty and Stenting for Symptomatic Intracranial Stenosis ‐ A Case Series

Introduction : Early and long‐term results of the SAMMPRIS trial showed superiority of aggressive medical management over stenting in patients with symptomatic intracranial stenosis, in part due to the high risk of periprocedural complications. However, even with maximal medical management, the risk of recurrent TIA or stroke in patients with high‐grade stenosis often remains elevated. Methods : A review of our stroke database was conducted, identifying three relevant cases. Results : CASE 1: A 69 year‐old man with multiple vascular risk factors and atrial fibrillation on apixaban presented with several months of multiple stereotyped episodes of limb‐shaking TIAs affecting the left leg, often leading to falls. CT angiogram revealed 70–80% stenosis of A2 segment of right ACA. Symptoms completely resolved after stenting with Neuroform Atlas stent. Repeat angiogram at 6 months showed excellent vessel caliber. CASE 2: A 78 year‐old man with hypertension, DM, CAD, and known left ICA occlusion presented with recurrent episodes of aphasia and right arm weakness while on maximal medical therapy. CT angiogram showed severe right supraclinoid ICA stenosis which was corrected with Resolute Onyx DES stent with improvement of symptoms. CASE 3: A 77 year‐old with hypertension, DM, CAD and aortic dissection on dual antiplatelet therapy and high‐intensity statin was admitted with stereotyped, blood pressure‐dependent episodes of aphasia and right face/arm weakness secondary to high‐grade stenosis of both M2 divisions of the left MCA. Successful angioplasty and Y‐stenting with Neuroform EZ and Wingspan stents led to complete resolution of symptoms. Conclusions : At high‐volume centers and with newer interventional devices and techniques, intracranial angioplasty and stenting should be considered as a valuable therapeutic option in patients with symptomatic intracranial stenosis refractory to maximal medical therapy.

Dynamic right-to-left interatrial shunt may complicate severe COVID-19

Right-to-left (RTL) interatrial shunt (IAS) may complicate select cases of COVID-19 pneumonia. We describe the use of serial imaging to monitor shunt in critically ill patients. A 52-year-old man presented with COVID-19 pneumonia. Hypoxia worsened despite maximal medical therapy and non-invasive ventilation. On day 8, saline microbubble contrast-enhanced transthoracic echocardiography revealed a patent foramen ovale (PFO) with RTLIAS. Invasive ventilation was initiated the next day. The course was complicated by intermittent severe desaturation without worsening aeration or haemodynamic instability, so PFO closure was considered. However, on day 12, saline microbubble contrast-enhanced transoesophageal echocardiography excluded RTLIAS. The patient was extubated on day 27 and discharged home 12 days later. Thus, RTLIAS may be dynamic and changes can be detected and monitored by serial imaging. Bedside echocardiography with saline microbubble contrast, a simple, minimally invasive bedside test, may be useful in the management of patients with severe hypoxia.

Efficacy of Low-Dose versus High-Dose Continuous Cyclic Azithromycin Therapy for Preventing Acute Exacerbations of COPD

<b><i>Background:</i></b> Long-term azithromycin therapy significantly reduces the frequency of COPD exacerbations (ECOPD). However, previous studies have used different dosing regimens, and the efficacy of these regimens has not been compared. <b><i>Objective:</i></b> Compare the efficacy of low-dose with high-dose continuous cyclic azithromycin (CC-A) in severe COPD. <b><i>Methods:</i></b> Patients with severe COPD and repeated exacerbations (ECOPD ≥4 or ≥3 with at least 1 hospital admission in the previous year) were prospectively recruited (January 2017 to December 2019) as a multicenter cohort (from 3 university hospitals in the Barcelona area) and treated with low-dose CC-A: 250 mg 3 times per week (250-CC-A group). This cohort was compared with a historical (January 2007 to December 2013) single-center cohort of severe COPD with frequent ECOPD treated with high-dose CC-A: 500 mg 3 times per week (500-CC-A group). To assess differences in ECOPD prevention according to the administration of low-dose or high-dose CC-A, moderate-to-severe ECOPD was evaluated during the 12-month period before and after starting CC-A therapy. <b><i>Results:</i></b> Fifty-eight patients with severe COPD were evaluated: 37 in the low-dose group and 21 in the high-dose group. The 250-CC-A therapy group achieved a mean reduction in moderate-to-severe ECOPD of 65.6% at 12 months after starting CC-A therapy (with a 61.5% reduction in hospitalizations), while the 500-CC-A group achieved a reduction of 60.5% (with a 44.8% reduction in hospitalizations). No significant differences between 250-CC-A and 500-CC-A dosages were observed in the mean annual reduction of moderate-to-severe ECOPD (<i>p</i> = 0.55) or hospitalizations (<i>p</i> = 0.07) with respect to the year prior to starting CC-A. <b><i>Conclusions:</i></b> Low-dose 250-CC-A therapy over a 1-year period is similar to high-dose 500-CC-A in reducing exacerbation frequency in severe COPD patients with frequent ECOPD despite maximal medical therapy.

THE OUTCOMES OF TRABECULECTOMY WITH ADJUNCTIVE SUBCONJUNCTIVAL MITOMYCIN C AMONG PATIENTS REQUIRING GLAUCOMA SURGERY AT A TERTIARY CARE HOSPITAL IN RAJASTHAN, INDIA

Introduction: Glaucoma is a chronic multifactorial degenerative optic neuropathy and is the second leading cause of irreversible blindness worldwide. Material And Methods: 50 eyes of 50 patients of diagnosed glaucoma not controlled by maximal medical therapy underwent trabeculectomy adjuncted with subconjunctival Mitomycin C. Preoperative data included age, gender, IOP(intraocular pressure) and number of preoperative medications. Postoperatively IOP, number of glaucoma medications and postoperative complications if any were recorded on follow up at seven days, one month and three months. Results: Baseline characteristics were matched. Preoperative IOP was 33.23±8.41 mm of hg which drastically dropped to 14.67±5.78 mm of hg 3 months postoperatively. The need for postoperative antiglaucoma medications also dropped from 3.92±1.14 medications used preoperatively to 1.14±1.26 postoperatively. Success rate was 50% out of which 46% had complete success while 44% had qualied success. Postoperative complications seen were hypotony(14%), Flat AC(12%), Hyphema (6%), Flat Ac with raised IOP(2%), and Cystoid macular edema (2%). Discussion: In conclusion, this study shows that trabeculectomy with adjunctive MMC provides good patient outcome in the form of treatment success in 90% and reduced postoperative antiglaucoma medications in patients and is a good alternative to trabeculectomy alone.

Comparison of Treatment Outcomes of Selective Laser Trabeculoplasty for Primary Open-Angle Glaucoma and Pseudophakic Primary Angle-Closure Glaucoma Receiving Maximal Medical Therapy

Selective laser trabeculoplasty (SLT) is a useful treatment for intraocular pressure (IOP) control. However, there are only a few reports which compare the outcomes of SLT between primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG). We compared the efficacy of SLT for patients with PACG following phacoemulsification with POAG receiving maximal medical therapy (MMT). Consecutive glaucoma patients followed up for at least 1 year after SLT were retrospectively evaluated and IOP reductions at 6 months and 12 months were analyzed. Seventy-six patients were included in the analyses. The baseline IOPs in the POAG and PACG group were 18.5 ± 3.3 mmHg and 16.9 ± 2.5 mmHg, respectively, with 2.8 ± 0.9 and 2.7 ± 0.8 types of IOP lowering medication. The average IOP at the 6-month and 12-month follow-up after SLT was significantly decreased and comparable in both the POAG and PACG groups. For those with a low baseline IOP, the effect of SLT on IOP reduction at 12 months was significantly better in the PACG than in the POAG group (p = 0.003). IOP reduction at 6 and 12 months after SLT was significantly greater in those with a high baseline IOP than those with a low baseline IOP (p < 0.0065). In summary, the one-year efficacy of SLT was equivalent in POAG and pseudophakic PACG patients receiving MMT; however, SLT was more effective in eyes with PACG than eyes with POAG when focusing on those with a lower baseline IOP.

Chronic rhinosinusitis: medical versus surgical management

<p class="abstract"><strong>Background:</strong> Management protocols of chronic rhinosinusitis (CRS) recommend initial treatment with maximal medical therapy with surgery reserved for refractory cases. Literature comparing the effectiveness of these two treatment modalities is limited. The purpose of this study was to compare the outcome of medical and surgical management for CRS.</p><p class="abstract"><strong>Methods:</strong> This was a prospective cohort study. Patients registered for the study were diagnosed as CRS based on history, clinical examination and investigation findings. All patients were initially subjected to medical management for 3 weeks and refractory cases were then subjected to surgical intervention. Subjective and objective improvements assessed with SNOT-22 score and Lund-Kennedy (LK) score respectively were analysed statistically.</p><p class="abstract"><strong>Results:</strong> Out of the 100 patients registered for the study, 37% had nasal polyposis while 63% were without polyposis. When subjective and objective improvements were compared between groups receiving medical management alone and those receiving combined management, the difference was not found to be statistically significant (p&lt;0.05).</p><p class="abstract"><strong>Conclusions:</strong> Although the decision regarding treatment modality to be used in CRS should depend on individual case, all cases can be subjected to a maximal medical therapy initially while reserving surgery for cases which do not improve.</p>