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Bernard Dib,1–4 Robert E Morris,1–4 Matthew H Oltmanns,1–4 Mathew R Sapp,1–4 Jay P Glover,5 Ferenc Kuhn2,6,7 1Retina Specialists of Alabama, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, Al, USA; 3University of Alabama at Birmingham (UAB), Department of Ophthalmology, Birmingham, Al, USA; 4UAB Callahan Eye Hospital, Birmingham, Al, USA; 5Retina Consultants of Nashville, Nashville, TN, USA; 6Milos Eye Hospital, Belgrade, Serbia; 7Zagorskiego Eye Hospital, Krakow, PolandCorrespondence: Robert E MorrisRetina Specialists of Alabama, 2208 University Blvd, Ste. 101, Birmingham, Al, 35233, USAEmail rmorris@retinanetwork.com View the original paper by Dr Dib and colleagues This is in response to the Letter to the Editor

Bernard Dib,1– 4 Robert E Morris,1– 4 Matthew H Oltmanns,1– 4 Mathew R Sapp,1– 4 Jay P Glover,5 Ferenc Kuhn2,6,7 1Retina Specialists of Alabama, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, AL, USA; 3University of Alabama at Birmingham (UAB), Department of Ophthalmology, Birmingham, AL, USA; 4UAB Callahan Eye Hospital, Birmingham, AL, USA; 5Retina Consultants of Nashville, Nashville, TN, USA; 6Milos Eye Hospital, Belgrade, Serbia; 7Zagorskiego Eye Hospital, Krakow, PolandCorrespondence: Robert E MorrisRetina Specialists of Alabama, 2208 University Blvd, Ste. 101, Birmingham, AL 35233, USAEmail rmorris@retinanetwork.comPurpose: In this study, we report the treatment outcomes of complete and early vitrectomy for endophthalmitis (CEVE) after cataract surgery as the predominate initial treatment, accompanied by systemic antibiotics and retreatment of persistent or recurrent purulence (CEVE+).Patients and Methods: Clinical features and microbiological factors were retrospectively reviewed in 62 eyes of 62 patients who were treated for acute postcataract endophthalmitis (APCE) occurring within three weeks of cataract surgery at Retina Specialists of Alabama, between 2007 and 2017.Results: Visual acuity on presentation included light perception (LP) in 18 eyes (29%) and hand motion (HM) in 23 eyes (37%). Initial treatment was maximum possible vitrectomy in 48 eyes (77%) and tap-and-inject in 14 eyes (23%), with 38 eyes (61%) receiving two or more treatments. Cultures for the first intervention were positive in 49 eyes (79%) and virulent in 18 eyes (29%). At a median follow-up time of five months, final visual acuity was ≥ 20/40 in 49 eyes (79%), between 20/50 and 5/200 in seven eyes (11%), and < 5/200 in six eyes (10%). Virulence was the strongest predictor of poor visual outcome. Retinal detachment occurred in four eyes (6%), likely from necrotic retinal defects in each case.Conclusion: Complete and early vitrectomy is a safe and effective initial treatment for APCE. When accompanied by systemic antibiotics and retreatment (CEVE+) of recurrent media opacification, it improves recovery of 20/40 or better visual acuity by approximately 50% compared to a predominantly tap-and-inject treatment paradigm. We recommend CEVE for fundus-obscuring APCE (∼ 75% of all cases) whenever the view is inadequate to rule out macular distress.Keywords: endophthalmitis, postcataract endophthalmitis, vitrectomy, tap and inject, TAP, VIT, EVS, APCE

The improvement of the quality of life within the residential environment is the ultimate objective of sustainable development, in which its environmental, economic and social dimensions are constantly identified and updated. To this end, the development of a reference framework for the actors of the housing sector can formulate new policy trends related to the planning and design of the residential environment. Post-occupancy evaluation is an appropriate method for assessing and evaluating the impact of housing policies on residents' behaviour. Then, the results of these policies are tested by measuring residential satisfaction and by determining the factors that affect it. To achieve this objective, the technique of a head-of-household interview form was used. We relied on eighteen well-known potential variables in studies related to housing satisfaction, focusing on the social dimension. A sample consisting of two social housing clusters in the city of Boussaâda, comprising 121 households was randomly selected. Finally, the data were statistically processed using a factor analysis which is the principal components method, through which four factors containing fourteen variables that control residential satisfaction were extracted.

Purpose: To evaluate the visual outcomes with unexplained vision loss during or after silicone oil (SO) tamponade. Methods: This multicenter retrospective case series comprised patients with unexplained vision loss associated with SO tamponade or its removal. Eyes with other clear secondary identifiable causes of vision loss were excluded. Results: Twenty-nine eyes of 28 patients (64% male) were identified. The mean age was 50 ± 13 years (range, 13-78 years). The mean duration of SO tamponade was 148 ± 38 days. Eighteen eyes (62%) developed unexplained vision loss while under SO; 11 (38%) had vision loss after SO removal. The most common optical coherence tomography (OCT) finding was ganglion cell layer (GCL) thinning (55%). Eyes with vision loss after SO removal had a mean logMAR best-corrected visual acuity (BCVA) of 0.6 ± 0.7 (Snellen 20/85) before SO tamponade and 1.2 ± 0.4 (20/340) before SO removal. By the last follow-up after SO removal, the BCVA had improved to 1.1 ± 0.4 (20/235). In eyes with vision loss after SO removal, the BCVA before SO removal was 0.7 ± 0.7 (20/104), which deteriorated to 1.4 ± 0.4 (20/458) 1 month after SO removal. By the last follow-up, the BCVA had improved to 1.0 ± 0.5 (20/219). Conclusions: Unexplained vision loss can occur during SO tamponade or after SO removal. Vision loss was associated with 1000-centistoke and 5000-centistoke oil and occurred in macula-off and macula-on retinal detachments. The duration of tamponade was 3 months or longer in the majority of eyes. Most eyes had GCL thinning on OCT. Gradual visual recovery can occur yet is often incomplete., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Yannuzzi is on Advisory Board of Genentech and RegenXbio. Dr. Mantopoulos is a consultant to Alimera Sciences. Dr. Goduni has served on the Alimera Fellows Advisory Board and is an independent contractor for Clover Therapeutics. Dr. Jung is a consultant to Carl Zeiss Meditec, Inc., (© The Author(s) 2023.)

Background: This single center study compares the different surgical techniques used in the treatment of acute aortic dissection type A (AADA) analyzing the influence of the extent of the surgical approach on outcome., Methods: From 1988 to 2012, 407 patients were operated for AADA. The cohort was divided into subgroups according to the surgical approach. These groups were compared with the supracommissural replacement group (SCR; n = 141). Groups included aortic valve sparing techniques (AVS; n = 29), Composite replacement (COMP; n = 119), COMP with total arch replacement (COMP+TAR; n = 27) and SCR with TAR (n = 75)., Results: Compared to SCR alone, operation (p = 0.005), bypass-, cross-clamp and circulatory arrest times were longer in SCR + TAR (all p < 0.001). Moreover, operation, bypass and cross clamp times were longer in COMP+TAR (p = 0.003, p = 0.002 and p < 0.001 respectively). COMP alone and AVS required longer cross-clamp time, too (p < 0,001 and p = 0.002, respectively). Overall 30-day mortality was 21% with the observed lowest rate after AVS (14%, SCR 18%, COMP 25%) but differences in 30-day mortality were not statistically significant. The estimated 10-year survival was 42%, especially AVS demonstrated a good 10-year survival (69%). David technique was superior to Yacoub technique concerning incidence of redo interventions (p = 0.036). Risk factors for early mortality included age, circulatory arrest, general malperfusion, bypass and operation time. Circulatory arrest per se was revealed as risk factor for long-term survival., Conclusions: Within our single center retrospective study concomitant aortic root repair or aortic arch replacement for AADA demonstrated acceptable early and long-term survival. Circulatory arrest, long bypass and operation times per se might be important risk factors for early mortality. AVS techniques can be performed safely and have good outcomes in acute aortic dissection repair.

Background: The frozen elephant trunk (FET) technique was developed to facilitate the two-stage surgery of extensive pathologies of the thoracic aorta and is now routinely applied in acute and chronic aortic syndromes., Methods: From 11/2006 to 07/2017, 68 patients underwent aortic arch repair using the FET technique. Patients received either the Jotec E-vita Open graft (n = 57) or the Vascutek Thoraflex hybrid prosthesis (n = 11). Both, group 1 (acute aortic dissection type A and B; symptomatic penetrating aortic ulcer) and group 2 (aortic aneurysm; chronic aortic dissection) included 34 patients each., Results: Early mortality was 13.2% (14.7% in group 1 vs. 11.7% in group 2, p = 0.720). Neurological complications occurred in 12 patients (17.6%) (stroke: 8.8 vs. 11.7%; p = 0.797 and spinal cord injury: 8.8 vs. 5.9%; p = 0.642 in groups 1 vs. 2 respectively). Cardiopulmonary bypass time and cross clamp time were significantly longer in group 1 (252.2 ± 73.5 and 148.3 ± 34 min vs. 189.2 ± 47.8 and 116.3 ± 34.5 min; p <  0.001). The overall 1-, 3- and 7-year-survival was 80.9, 80.9 and 74.2% with no significant differences between groups 1 and 2. Expansion of true lumen after FET implantation was significant at all levels in both groups for patients with aortic dissection. One-, 3-, and 7-year-freedom from secondary (re-)intervention for patients for aortic dissection was 96.9, 90.2 and 82.7% with no significant differences between groups 1 and 2; p = 0.575., Conclusion: The FET technique can be applied in acute aortic syndromes with similar risks regarding adverse events or mortality when compared to chronic degenerative aortic disease. Postoperative increase in true lumen diameter mirrors decrease of false lumen diameter, goes along with favorable midterm outcome and prolongs freedom from secondary interventions in acute aortic dissection.

Objective: Open surgical repair of thoracoabdominal aortic aneurysm remains an important treatment option and continues to be challenging. The objective of this study was to investigate the results after open repair of thoracoabdominal aortic aneurysms in a contemporary non-high-volume center collective., Methods: A total of 38 patients underwent operation for thoracoabdominal aortic aneurysm between August 2007 and April 2017. Patients had aortic aneurysm and chronic aortic dissection. The majority of patients had already undergone previous aortic interventions., Results: The mean age was 54.4 ± 13.4 years (range, 29-72.5 years), and 22 patients (57.9%) were female. Most commonly, patients (57.9%) presented with Crawford type II aneurysms. The mean cardiopulmonary bypass time was 159 ± 65 minutes. The operative mortality was 10.5% (n = 4). The paraplegia rate and the incidence of stroke were 7.9% (n = 3). Postoperatively, 4 patients (10.5%) required temporary hemodialysis. In 4 patients (10.5%), reexploration due to bleeding was necessary. Sepsis developed in 4 patients (10.5%). Preoperative renal insufficiency was identified as a predictor of mortality. The patients were discharged from the hospital after a median length of stay of 21.5 days. The 1-year survival was 83%., Conclusions: Despite the invasiveness of open thoracoabdominal aortic repair and significant risk of major complications, surgical repair can be accomplished in a non-high-volume center with acceptable results., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Minimally invasive mitral valve surgery (MVS) via right mini-thoracotomy has recently attracted a lot of attention. Minimally invasive MVS shows postoperative results that are comparable to those of conventional MVS through the median sternotomy as per various earlier studies., Methods: Between 2000 and 2016, a total of 669 isolated mitral valve procedures for isolated mitral valve regurgitation were performed. A propensity score-matched analysis was generated for the elimination of the differences in relevant preoperative risk factors between the cohorts and included 227 patient pairs. Only degenerative mitral valve regurgitation was included. The aim of our study was to examine if the minimally MVS is superior to the conventional approach through sternotomy based on a retrospective propensity-matched analysis. The primary endpoints were early mortality and long-term survival. The secondary endpoints included postoperative complications., Results: The in-hospital mortality rate was significantly higher within the conventional sternotomy cohort (3.1%, n = 7 vs 0.4%, n = 1 for the minimally invasive cohort; p = 0.032). The incidence of stroke and exploration for bleeding was comparable. In contrast, the necessity for dialysis was significantly lower in the minimally invasive cohort ( p = 0.044). Postoperative pain was not significantly lower in the minimally invasive MVS cohort ( p = 0.862). While patients who underwent minimally invasive MVS experienced longer bypass and cross-clamp times, their lengths of stay in the intensive care unit and in the hospital, did not differ from the conventionally operated collective ( p = 0.779 and p = 0.516), respectively. The mitral valve repair rate of 81.1% in the minimally invasive cohort was significantly superior to that of the conventional approach, which was 46.3% ( p < 0.0001). The one-, five-, and 10-year survival rates were significantly higher in the minimally invasive cohort compared to the conventional approach (96%, 90%, and 84% vs. 89%, 85%, and 70%; log rank p = 0.004)., Conclusion: Despite prolonged cardiopulmonary bypass and cross-clamping times, the minimally invasive MVS may be considered a safe approach that is equivalent to standard median sternotomy with lower early mortality and superior long-term survival., Competing Interests: The authors declare that they have no competing interests.

BACKGROUND The aim of this study was to investigate the clinical presentation, operative data, and early and late outcomes of a large patient cohort undergoing surgical treatment for cardiac tumors in our institution. MATERIAL AND METHODS A total of 181 patients underwent surgery because of suspected cardiac tumor in our institution between 1998 and 2016. In 162 cases, the diagnosis was confirmed postoperatively and these patients were included in this study. Preoperative baseline characteristics, operative data, and postoperative early and long-term outcomes were analyzed. RESULTS Mean age at presentation was 56.6±17.6 years, and 95 (58.6%) patients were female. There were 126 (77.8%) patients with benign cardiac tumors, while the remaining patients had malignant tumors (primary and metastasized). The mean follow-up time was 5.2±4.7 years. The most frequent histologically verified tumor type was myxoma (63%, n=102). In terms of malignant tumors, various types of sarcomas presented most primary malignant cardiac tumors (7.4%, n=12). The mean ICU length of stay was 1.7±2.2 days and overall in-hospital mortality was 3.1% (n=5). Frequent postoperative complications included mediastinal bleeding (5.8%, n=9), wound infection (1.3%, n=2), acute renal failure (5.6%, n=9), and major cerebrovascular events (n=7, 4.6%). The overall cumulative survival after cardiac tumor resection was 94% at 30 days, 85% at 1 year, 72% at 5 years, and 59% at 15 years. CONCLUSIONS Surgical treatment of cardiac tumors is a safe and highly effective strategy associated with good early and long-term outcomes.

BACKGROUND Overall, life expectancy at the age of 80 has significantly increased in the industrialized world and the proportion of this age class undergoing cardiac surgery has also grown. In this context, we have analyzed a contemporary series of octogenarians undergoing mitral valve surgery at our institution. MATERIAL AND METHODS We performed a retrospective analysis of 138 consecutive octogenarians receiving mitral valve surgery between January 2006 and April 2017. Preoperative comorbidities, early mortality, postoperative clinical course, and predictors of mortality were examined. RESULTS The mean age was 82.4±2.0 years and 50% (n=69) were male. Preoperative comorbidities included history of heart infarction (24.6%, n=34), chronic renal failure (37.7%, n=52), and COPD (27.5%, n=38). A total of 52.9% (n=73) had a history of previous cardiac decompensation, while 20 (14.5%) presented with cardiogenic shock or cardiac arrest. In all, 33 patients (23.9%) underwent emergency surgery. There were only 39 isolated mitral valve procedures, while 99 patients (71.7%) underwent various concomitant procedures. The intensive care unit average length of stay was 5.3±7.5 days. Respiratory complications and sepsis were the most frequent postoperative complications. Emergency surgery and concomitant coronary artery bypass grafting were the most important predictors of early mortality. The overall 30-day mortality was 18.1% (n=25). The mean follow-up time was 1.7±2.3 years. CONCLUSIONS Octogenarians are increasingly represented in cardiac surgery and combined procedures. Prudent patient selection is necessary for optimizing postoperative outcomes among the elderly. In our seriously ill octogenarian cohort, mitral valve surgery was associated with moderate but acceptable mid-term survival.

BACKGROUND We reviewed our clinical experience with cardiac papillary fibroelastoma from 2005 to 2017. The objective of this study was to investigate the clinical and operative data, as well as the early survival rate and immediate postoperative complications. MATERIAL AND METHODS We performed a retrospective analysis of 11 patients (eight males and three females) who underwent resection of cardiac papillary fibroelastoma in our institution. RESULTS Mean age at tumor diagnosis was 60±14 years. The mean dimension of the tumor was 14±11 mm. The most common symptoms were dyspnea, palpitation, and angina pectoris, while one patient had recurrent fever attacks and another patient had a transient ischemic attack. Two patients had concomitant malignant tumors (cervical and colon carcinoma) and another two had concomitant benign neoplasms (liver cyst and thyroid adenoma). Bypass and cross clamp times were 77±32 minutes and 54±18 minutes, respectively. The tumors were found predominantly on cardiac valves (n=7). In eight cases, only tumor extirpation was performed, whereas in the other three cases, the valves had to be replaced. The mean intensive care unit length of stay was 1.1±0.3 days and there was no in-hospital mortality. All patients were alive at one-year follow-up and the survival rate was 91% in the mean follow-up period of 4.15 years. CONCLUSIONS The surgical treatment of cardiac papillary fibroelastoma was curative and safe. Thus, potential complications such as embolization or mechanical irritation of the valves can be avoided without high surgical risk.

Oxidative stress has been shown to contribute to the development of age-related macular degeneration (AMD). MicroRNAs (miRNA) are small non-coding RNA molecules that function in RNA silencing and post-transcriptional regulation of gene expression. We showed miR-17-3p to be elevated in macular RPE cells from AMD patients and in ARPE-19 cells under oxidative stress. Transfection of miR-17-3p mimic in ARPE-19 induced cell death and exacerbated oxidative lethality that was alleviated by miR-17-3p inhibitor. The expression of antioxidant enzymes manganese superoxide dismutase (MnSOD) and thioredoxin reductase-2 (TrxR2) were suppressed by miR-17-3p mimic and reversed by miR-17-3p inhibitor. These results suggest miR-17-3p aggravates oxidative damage-induced cell death in human RPE cells, while miR-17-3p inhibitor acts as a potential protector against oxidative stress by regulating the expression of antioxidant enzymes.

Purpose: TUNEL assay is widely used to evaluate cell death. Quantification of TUNEL-positive (TUNEL+) cells in tissue sections is usually performed manually, ideally by two masked observers. This process is time consuming, prone to measurement errors, and not entirely reproducible. In this paper, we describe an automated quantification approach to address these difficulties., Methods: We developed an ImageJ macro to quantitate cell death by TUNEL assay in retinal cross-section images. The script was coded using IJ1 programming language. To validate this tool, we selected a dataset of TUNEL assay digital images, calculated layer area and cell count manually (done by two observers), and compared measurements between observers and macro results., Results: The automated macro segmented outer nuclear layer (ONL) and inner nuclear layer (INL) successfully. Automated TUNEL+ cell counts were in-between counts of inexperienced and experienced observers. The intraobserver coefficient of variation (COV) ranged from 13.09% to 25.20%. The COV between both observers was 51.11 ± 25.83% for the ONL and 56.07 ± 24.03% for the INL. Comparing observers' results with macro results, COV was 23.37 ± 15.97% for the ONL and 23.44 ± 18.56% for the INL., Conclusions: We developed and validated an ImageJ macro that can be used as an accurate and precise quantitative tool for retina researchers to achieve repeatable, unbiased, fast, and accurate cell death quantitation. We believe that this standardized measurement tool could be advantageous to compare results across different research groups, as it is freely available as open source.

The degradation and epimerization of ergot alkaloids (EAs) in rye flour were investigated after baking cookies and subsequently subjecting them to an in vitro digestion model. Different steps of digestion were analyzed using salivary, gastric, and duodenal juices. The degradation and bidirectional conversion of the toxicologically relevant (R)-epimers and the biologically inactive (S)-epimers for seven pairs of EAs were determined by a HPLC method coupled with fluorescence detection. Baking cookies resulted in degradation of EAs (2-30 %) and a shift in the epimeric ratio toward the (S)-epimer for all EAs. The applied digestion model led to a selective toxification of ergotamine and ergosine, two ergotamine-type EAs. The initial percentage of the toxic (R)-epimer in relation to the total toxin content was considerably increased after digestion of cookies. Ergotamine and ergosine increased from 32 to 51 % and 35 to 55 %, respectively. In contrast, EAs of the ergotoxine type (ergocornine, α- and β-ergocryptine, and ergocristine) showed an epimeric shift toward their biologically inactive (S)-epimers. Further experiments indicated that the selective epimerization of ergotamine EAs occurs in the duodenal juice only. These results demonstrate that toxification of EAs in the intestinal tract should be taken into consideration.